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5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 5209) 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. j Job Address \� ►�f�� A City Loa i Lot Size 5 M_RE-i PM _ f 47bOwner's Name Address Phone I Contractor �� ' Address SEvv� License No. _771 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing / V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l 1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout —. Y I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by - Repair-Work Done ❑ Type of Pump H.P. State Work Done Well Destruction_. ❑ Well Diameter Sealing Material (top 501 w Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is _ available within 200 feet.) i Installation will serve: Residence Commercial �Other 'Number of living units: --j— Number of bedrooms y ) F Character of soil to a depth of 3 feet: ,t� Water table depth ` SEPTIC TANK OldjyY e/Mfg b2l 0- --r>f Capacity No. Compartments PKG. TREATMENT PLT. ❑ fp Method of Disposal Distance to nearest: Well�/ d Foundation Property Line v LEACHING LINE K— No. & Length of lines `7 ylf Total length/size d • FILTER BED Distance to nearest: Well_��. Foundation 15,f77�__ Property LineC� j, SEEPAGE PITS Depth �1 Size Number t SUMPS Ll Distance to nearest: Well . _ Foundation f 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 taws,,,an� rules and regulations of the San Joaquin Local Health Dr'?;trict. 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 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 lawsof Cali rnia." t The applicant st call r all r fired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR D PARTMENT USE ONLY _ Application Acceptedby Date L _, Area Pit or Grout;Inspection by � Date f- "`'lI—��Final Inspection by Date -� Additional Comments:/ / } `` CJS f ` ❑ Stk 466-6781 ❑ 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 2409, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO /�y7y� I CASH( +.EH1324(REV.r/85). 60 / %4d ? J ZW 1 '�� r r EH 14.24 Si - - -