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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.,HAZELiUWA,,VE., STOCKTON, CA Telephone (20 ) 466-6781- PERMIT EXPIRES 1 YEAR F OM:.DATE ISSUED ` w -.,,(Complete in Triplicate) .,, 211t ! Application is hereby made to the San Joaquin Local Health District for a permit to c&struct 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-t Local Health District. he Rules and Regulations of the San Joaquin - Job Address Al p /Y1 l�✓l10/LJ r' " �,' -. city 7r2�k Lot Size PM - - _ -.. _ Owner's Name S f Address Q 7-- Co .S - Phone 6 Contractor's Name UAtt V�,m ,L- 1/QU/rt7" License No. —1 �g �r Phone G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTACLATION,:� SYSTEM REPAIR ❑ OTHER ❑ ..J 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing Q domestic/Private X.Gravel Pack Tracy Type of Casing w Jrogiublic / P . ❑ Other ❑ Delta Depth of Grout Seal Specifications .0 Irrigation -- Type of Grout --Approx. Depth ❑ Eastern Surface Seal installed by p Repair Work pone ❑4 Type of Pump SUB _ H.P. State Work Done L`!_ nti-P Well Destruction 0 4 Well Diameter ' Sealing Material (top 501 „ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:T NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial available within 200 feet.) _ Other c Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK,,, ❑ Type/Mfg Capacity— h PKG. TREATMENT PLT. ❑ No. Compartments f Method of Disposal #` Distance to nearest: Well Foundation 'Property Line LEACHING LINE +❑ No. & Length of lines t Total length/size FILTER BED - q 'Distance to net Well Foundation @ Property Line SEEPAGE PITS ❑ Depth j Size Number Plk SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS LlFoundation Property Line 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 District. 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 i certifies the following: 'I certify that m the performance of the work for which this permit is issued,1.1 shall employ persons subject to workman's compensa- i tion laws of California." The applicant must II for aired inspections. Complete drawing on reverse side. A Signed v �� _SG _ Title: .. Date: FOR DEPARTMENT USE ONLY Application Accepted F Date (f Area Pit or Grout Inspection by Date Final Inspection by !� Date Additional Comments: i € d ❑ Stk 466-6781 - ❑ Lodi 369-3621 YC Manteca '823-7104 ❑ Tracy .. , ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.la/83 i EH 14-26 _