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APPLICATION FOR PERMIT IL SAN JOAQUIN LOCAL HEALTH DISTRICT o 1601 E. HAZELTON AVE., STOCKTON, CA MAY 1 59.87 Telephone {2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH (Complete in Triplicate) FERMITAERVICES 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 t� City &A Lot Size PM Owner's Name '1 X/- Address 3 3 (�S2 • i"r a Phone z 25 Contractor 5� Address i�J�S ood&4Gr ;/�6 License No. 62Qa8i3 Phone TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK n07le_ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL J2 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom )Manteca Dia. of Well Excavation // __ Dia. of Well Casing `(Domestic/Private )K Gravel Pack ❑ Tracy Type of Casing )ayt✓ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal (SZ- YPe T of Grout / El Irrigation --Approx. Depth El Eastern Surface Seal Installed by LQ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ltop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: h Water table depth SEPTIC TANK ❑ Type/Mfg Capity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell Fou dati roperty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: We Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 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 appli ant ust call for,all requ' inspections. Complete drawing on verse sid Signed d6 Title: Date: FO PARTINT USE ONLY � N Application Accepted by Date Area Pit or Grout Inspection by 134te i &F' alspection b Date Additional Comments: / ❑ Stk 466-6781 ❑ odi 369- anteca Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO r + EH 13-24(REV.i/85) EH 14-26