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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA r. Telephone (209) 466-6781 3 'PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED t (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 r 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. ,e2f 3F Job Address r/✓ City Lot Size/, — PNf Owner's Name Phone 47 U 5r 47 7 Contractor ddress F icense N'.1:774&Phone TYPE OF WELL/PUMP: NEW WELL EJ WELL REPLACEMENT ❑ DES UCTIONEl 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 C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public 1.1 Other [1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameteracing Material (top 50'1 Depth r Filler Material (Below 50.) _ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I. I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_ Commercial— Other /1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg,( Capacity No. Compartments , PKG. TREATMENT PLT. ❑ Method of Disposal �/ V Distance to nearest: Well�_ Foundation Property Line �� LEACHING LINE Cl No. & Length.of lines s^ Total length/size (90 FILTER BED ❑' Distance tonearest: Well Foundation Property Line I ItI SEEPAGE PITS 11 Depth 1 Size ! 6 Number i SUMPS Cl Distance to nearest: Well Foundation Property Line —�—�—� DISPOSAL PONDS ❑ I ;i 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 Di§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 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: "t certify that in the performance of the work for which this permit is issuedr I shall ernploy persons subject to workman's compensa- tion laws of California." r �a T i The applicant must call for all requi a spections. Compl drawing on reverse,side. ;" Signed X Title:. Date: r FOR DEPARTMENT USE ONLY r Application Accepted by Date ,'Area Pit or Grout Inspection by Date 2 Final'lnspection by Date Additional Comments: fU Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 ,E Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201''- (NFO FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT*NO. a.EH 13-24.tREV.1/85) J Fv EH 14-26` - O� r�✓