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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. 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. Job Address 7 �,�� City IDIJ Lot Size PM Owner's Name e��Eu�. P1 Address 106 OLS ��2(!J Phone Contractor Address �Jy((J )11 f'� � License No. LC1:11J [5[�Phone Z1 v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION *-kplaU SYSTEM REPAIR ❑ 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 SPECIFICATIONS 11 Industrial El Open Bflttot� 'j.. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tl Domestic/Private ❑ Gtai el Pick,�• p Tracy Type of Casing Specifications I'I Public n Other *��In Delta Depth of Grout Seal Type of Grout__— I I Irrigation _ Approx.-Dep"_11 •I f-tastern Surface Seal Installed by Repair Work Done U Type of Pump _ --R-P, c2, State Work Done Well Destruction ❑ Well Diameter Sealing Materia 50. w6w I _ kJ f nLumP, Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION 1 I DESTRUCTION 1 1,(No septic system permitted if public sewer is available within.200 feet.) J/ \ 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ j Md1hod of 94osal Distance to nearest: Vyell. Foundation Property kine LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED L7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number._ -. SUMPS 11 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that-the-work will be done in acc; dance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di3trjct. Home owner or licensed agent's signature certifies the following: 'A certify that in the perfo'r—rnance 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 whit is�ermit is issued,I shall employ_ ersons�ubject-L4.ykRJkQldfl' compensa tion laws of ifo ia." •-- , ; The applic t mus call or coons Complete drawing r v rse side. Signed X Title: 4 Date: �L FOR DEPARTMENT USE ONLYIeK Applic Ion Accepted by �� D _k-e 15�_ 1 Area �7 Pit or Grout Inspection by Date Final Inspection by 1 Date L Additional Comments: O Stk 466-6781 O 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 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK N CASH RECEIVED BY DATE PERMIT NO. EM 13-24(REV.1/95) EM 14-26