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•t--APPLI.LCATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .� !� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 - v PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TINs 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. OJob Address City Lot Size 9 x PM Owner's Name Address . ` Phone Contractor dd ssl '(/ License No.IX5 Phone ! on- TYPE OF WELL/PUMP: Ar NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C7 !SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK EWER LINESISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE WE OTHER WELL PITS/SUMPS. INTENDED USE TYPE OF WELL PROBLEM A STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack `© Tracy Type of Casing f Specifications E) Public ❑ Other D pth of Grout Seal i` Type of Grout ❑ Irrigation --Approx. Depth astern Su ce Seal Installed by I Repair Work Done p Type of Pump H.P. State Work Done Well Destruction 117 Well Diameter Sealing Material {to p Depth Filler Materia! (Below 50 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRDITUNLO DESTRUC ION 171o septic system'permitted if public sewer is 1 t r variable within 20P feet.] r i Installation will serve:'#Residence---Commercial"" her' " �tabl, Number of living units: Number of bedrooms _ V1 Character of soil to a depth of 3 feet: *' T - Water depth c S lJ SEPTIC TANK ❑ Type/Mfg " dl Capacity No. Compartments v PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to neo t: Well Found t- Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTE 1 BED ❑ Distance to nearest: ell F undation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Pro * j party Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the rk wi a done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fol g: "I certify that in the performance of the work for which this per issued, I shall not employ any person in such manner as to become subject to orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of a work for which this permit is issued,I shall employ persons subject to workman's compensa- tion Ia%ivp,of,Cakifornia.'„� The applica ust call for I require inspections. Complete drawing on reverse side. Signed Title:��[J�L�� _ Date: _3-2-9-7 FOR DEPARTMENT USE ONLY Application Accepted by Da ,03,—,..— e7 Area l_J Pit or Grout Inspection by Date Final Inspection by Date ` Additional Comments: I& 0-Y, fi 7e ❑ Stk 466-6781 ❑ Lodi 3&3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. +£H 1324(REV.1/95) ` �� , � V2 JA EH 14-23P/S9 if