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m _ APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 s rM 9 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ( �: „:• (Complete in lTriplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This-applicaWn 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.' I I W r, „ ., 60 Job Address City Lot Size PM Owner's Name OF R / ' "' Address �[3 U L a p'� Phone 9 a"71 "a Contra t Address �� License No. Phone TYP OF WELL/IMP: NEW WELL ❑ `WELL REPLACEMENT p DESTRUCTION (f F -PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ OTHER` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESr'I, DISPOSAL FLD. PROP. LINE +: FOUNDATION ...r,� AGRICULTURE WELL OTHER WELL } PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 'W ,h4Dia. of Well Excavation r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 13 Irrigation _---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material (top 50') a Depth Filler Material(Below 501 —x TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0,,1DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Irving units: Number of bedrooms . Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines„ - 3 Total length/size r FILTER BED ❑ Distance to nearest: Well i Foundation Property Line r r SEEPAGE PITS ❑ iDepths Size Number SUMPS ❑ rDistance to nearestik 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.- i 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..becorne subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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." y; �r t The applic t st all for all r Tedi ns tion . Complate drawing on/reverse,side. Signe n Title Datei.�;2 FOR DEPART ENT,USE ONLY Application Accepted by ` ° ' Data Area t Pit or Grout Inspection by Date 1 Final Inspection by Date AdfOltional Comments: jik 466 67$1 ❑ B: i Lodi 369 3621 ❑ Manteca 82i-7104 ❑ Tracy 835 .<M1 Applicant`- Return all copies to`Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE- AMOUNT REMITTED RECEIVED BY DATE PERMIT`N INFO �j + EH 13-24IREV.)/95) .G -�! ��`.� .�Y_ C�_ K::J EH 1126 / ""V