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APPLICATION FOR PERMIT •. �„� �, 1601 E. HAZE T ON AVE., STOCKTON, CA R °` vC, C1, SAN JOAQUIN LOCAL HEALTH DISTRICT ''i� Telephone (2091466-6781 FEB 2 0 #1,9 k ; PERMIT EXPIRES 1 YEAR FROM DATE ISSUVIRQNMEN T A!- HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to the SanJoaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 04,c.: i Job Address T3(i C1 , (.(�V City Lot Size PM o -e Cue X33 Address Phone Owner's Name U n /` 23 �3 Phone !/. I Contractor ' Address ,.X License No/ca - I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEGIFiCATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. 04 Well Excavation Dia: of Well Casing _J I r Type of Casin Specifications C3-Domestic/Private ❑ Gravel Pack ❑ Tracy 9 _ i`] Public ❑ Other IF] Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. D th I I Eastern Surface Seal Installed by A Repair Work Done ( Type of PumState Work Done Pump H•P. f1 Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDIT10N l 3 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms— -Character of soil-to a-depth-of 3 feet:--------— ► »= Water-table-depth— �Capacity No. Compartments SEPTIC TANK Ll Type/Mfg r PKG. TREATMENT PLT. is 1 Method of Disposal y Distance to nearest: Well Foundation r Property Line i � a vc) LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 i� w Size �' � — Number SEEPAGE PITS I l Depth „ .._ SUMPS ❑ Distance to-nearest:-Well '�"'•"°Fouhdation Property Line { DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will be done in'accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. , Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to•become subject to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- , tion laws of California." The applica ust all for all required inspections. Complete drawing on reverse side. "tie: _ Date: Signed X_.. . U FOR DEPARTMENT USE ONLY J Date _;2 • Area fWa Application Accepted by Pit or Grout Inspection by� _ Date Final Inspection by Date�_1< I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 CK IV FEE AMOUNT DUE AMOUNT REMITTED�' CASH RECEIVED BY DATE PERMIT NO. INFO �j y ♦.EH 13-24(REV,t/85) EH 14-28 L