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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 �: yrs t rJ 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. F, } Job Address '�"_` � City Lot Size PM " Owner's Name Address ©� �' �' Phone I Contractor's Named License No. o� �p Phone 3 9] -,s 10 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E] Industrial Open Bottom•,--❑ Manteca--- - "Dia.of-Well Excavation - ---Dia. of-Well-Casing - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing` NSpecifications ❑ Public 11Other ❑ Delta Depth of Grout-Seal `-}"- ^ " i Type of Grout ❑Arrigatiorn•-->•�----.-- _---Approx. Depth .❑ Eastern - - -Surface Seal Installed by-- - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth r Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIRtADDITION iJ-DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence A-`, Commercial_ Other Number of living units: Number cl bedrooms �' f Character of soil to a depth of 3 feet: `t 1 I Water table depth�'�° t SEPTIC TANK ❑ • Type/Mfg ' Capacity No. Compartments i Method of Disposal PKG. TREATMENT PLT. ❑ f Distance to nearest: Well \Foundation " Property Lne i �. LEACHING LINE 4��No. & Length of lines �M � � Total length lsize 96X ` FILTER BED ❑ Distance to nearest: Well Foundation Qom— Property Line S,'+ — — er �r SEEPAGE PITS Depth - �� -Size �X -- - Number- y `� SUMPS ❑ Distance to nearest: Well .5992- = ~Foundation_10 i 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 perrriit.is issued, I shall not mpensation laws of California."Contractoi'�iairing or sub contracting signature employ any person in such manner as to become subject to workman's co certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persol s subject to workman's compensa- tion.laws of California." u The applic must call f all quired inspections. Complete drawing on reverse r Signed Title: Y Date: FOR DEPARTMENT USE ONLY 0 -+ Application Accepted by Dates_'_Z___4 Area Pit or Grout Inspection by Date Final Inspection by Data�� Additional Comments: -❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83545385 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 CASH RECEIVED BY DATE PERMIT"N0. INFO �{ + EH 13-24 4REV.10/93) �s , C."p EH 1429