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YL�, LI (� APPLICATION.FOR PERMIT LSAN 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 � , Job Address r�t1gLI F _ city,`"(J�t�� .Lot Size PM Owner's Name es e- .. Address .--_.L v _' "V W Il LXX ! L l�6�t� Phone Contractor's Name License No. J � / � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION C PUMP INSTALLATION SYSTEM REPAIR OTHER C �r DISTANCE TO NEAREST_ SEPTIC_TANKI SEWER LINES -------- Ar__._- 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 Well Excavation Dia. of Well Casing ^ `9 Domestic/Private ❑ Gravel Pack . ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth l Eastern Surface Seal Installed by Repair Work Done Type of Pump S" H.P. State Work Done Well Destruction C Well Diameter i:r Sealing Material [top 50') - -Depth -- �7�{�-- _._ _-Filler-Material (Below 50')-- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑DESTRUCTION 1711 ;(No septic system permitted if public sewer is -available within 200 feet.) 1 f Installation will serve: Residence_ Commercial_ Other Number of living units: Numberofbedrooms Character of soil to a depth of 3 feet 1 1' s. --____Water table depth SEPTIC TANK ❑ Type/Mfg I �. h Ja Y ) Capacity No. Compartments -_ PKG. TREATMENT PLT. ❑ i I Method of Disposal Distance to;nearest: Well rte` foundation Property Line 'LEACHING LINE ❑ No. & Length of lines __ `• -. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j• (SEEPAGE PITS C Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - iPI 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 Contractors 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- I tion laws of Califomia." The appficartlrust cak for all re uiTnsNctions. Complete drawing on revs a side. _ signed d Title: l�G r`��+ Date: ✓ 1 � - ` F DEPARTMENT USE ONLY Application Accepted by 1 Date Area Pit or Grout Inspection by — Date _ F al Inspection by��,. �(�19u Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 L] Manteca 823-7104 ❑ Tracy 835-6335 Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE , AMOUNT REMITFED CASH RECEIVED BY DATE PERMIYNO. + EH 1324(REV,1e/83) EH 1425 "�•c? 1