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c i - ry ,r APPLICATION FOR PERMIT ES 1 ` 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/a5-install the work herein described. This application is ` made in compliance with'San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/ um and the Rules and R ulations of the San J Local Health District. eg Joaquin 6 Job Address City •.575rCe/ Lot Size PM m Owner's Name Address Y Phone 6 1—S Contractor�G�tjD E:• Wpo� Address b0-C IBJ. )`L A, �Q f/E License.No. ��L7L __Phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial , _ ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack '❑.Trac" 1 Y Type of Casing Specifications ❑ Public ❑ Other kj ❑ Delta 5-i+t Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ' ❑rEastern` Surface Seal Installed by Repair Work Done ❑ Type of Pump. �.f H P.' State Work Done Well Destruction ❑ Well Diameter; Sealing Materia! (top 501 . Depth --------m —Fifler-Mpwial-(Below'501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION' ;No septic system permitted if public sewer is I 4available within 200 feet.) installation will serve: Residence_` Commercial_ Other j Number of living units:/ Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LlType/Mfg �' I« Capacity No. Compartments PKG. TREATMENT PLT. ❑ rd i !" Method of Disposal Distance to nearest: Well Foundation �_ Property Line LEACHING LINE ❑ No. & Length of lines Tota( length/size FILTER BED ❑ Distance to nearest:---Well-' ----� 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." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Data: S`7-S7 FOR DEPARTMENT USE ONLY Application Accepted by Date -Area 62 Pit or Grout Inspection by Date Final Inspection by Date �4 4-d' J ipplicant ditional Comments: =�_ Stk 466-6781 L7 Lodi 369-3511 = ❑ teca 823-7104 ❑ Tracy 835-6385 - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO -CASH RECEIVED BY DATE PERMINO. + EH 13-24(REV.1/85) �� -U _ �r-7 y�j EH W28 c C�C� �� ! S ''7 `� Q f`!d z