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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. AL Job Address VE v City '- Lot Size PM t �� — Address Phone Owner's Name) Contractor L LL Address ZS0 L^ N License No. p Phone 9 C 15,6 TYPE OF WELL/PUMP: NEW WELL-0 WELL REPLACEMENT O» DESTRUCTION ❑ 4l w., L _.�..,..,.,,-PUMP-.INSTALLATION-;Ll tf S.Y.STEM-REPAIR O--OTHER-M. -- BOTHER-©�.— ----�-» DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications mak°.. O..Public 'r O Other --E3-Delta^a'Delta��^ Y ^" Depth of-Grout-Seal _ '^''—." -�Ty`pe of-Grout`" ❑ Irrigation ---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 50') +Depth Filler Material (Below 501- ; TYPE OF SEPTIC WORK: NEW INSTALLATION [J REPAIR/ADDITIO N LE,BESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) + � 11 Installatio3 n will serve: Residence! ommercial_ Other Number of living units: Number o bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK L1 Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well . Foundation Property Line l LEACHING LINE 0--lo. & Length of lines 1 d'" Total length size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ I SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nest eli Foundation Property Line -- DISPOSAL PONDS 11i� )are^ I hereby certify that I have prepared this application and that the work will be done-in accordance with San Joaquin county ordinances, state lawsr 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- t s of Californi The applica t call r all r it �iinspecti �pleterawing on verse sl e:. Signe Title Date: , k. FOR DEPARTMENT USE'ONLY Application Accepted by I f Date [� Area (� Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haz`&ton Ave., P.O. Box 2009, Stk., CA 95201 i s i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO t aEH13-24(REV.I/85) EH 14-26 ., J