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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D �i 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N7AL ViEALTW (Complete in Triplicate) L�F�ERNII�/SERu10E$ 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. J � 67 Job Addressf'. 8a' � City Ira Lot Sizes ' �5 / PM Owner's Name (PAddress f•ir•WX V i611J -- Phone 93 0345 Contractor I'� Address 2 e Q E License No.—Z—(2gYZ3 Phone TYPE OF WELL/PUMP: NEW WELL * WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /OO ��_ SEWER LINES DISPOSAL FLD._IM PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS �t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private 00 Gravel Pack DO Tracy Type of Casingye— Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of GTut ' ❑ Irrigation 90_11 —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ W0 Diameter Sealing Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total 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,f shall employ persons subject to workman's compensa tion laws of California." The app ant ust call for all quir inspections. Complete drawing n eve side. Signed Title: Date: �! ""�7 r FOR DEPARTMENT USE ONLY �ry Application Accepted by / q Date /Al/97 Area a Pit or Grout inspection byDate ! G� Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. r INFO EH 13-241REV.1/85) y EH 14-28 no