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APPLICATION FOR PERMIT /f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAS Telephone (209) 466-6781 'i PERMIT EXPIRES I YEAR FROM DATE ISSUED /Jr i (Complete in Triplicate) l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t . 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 fhe Rules and Regulations of the San Joaquin Local Health District. Job Address City L�Tk}2� Lot Size�[1SC 1 PM Owner's Name Q�_`"L V, Address 1 � + Phone '_� Contractor's Name License No. Phone b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN7 ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAJR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF WELL— _ ROBLEM AREA CONSTRUCTION SPECIFICATIONS_- ❑ Industrial ❑ Open Bottom ❑ Manteca ��Wa.of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications �} ❑ Public ' ❑ Other „ :C3 Delta . Depth of Grout Seal Type of Grout • , ❑ Irrigation i - --Approx.rDepth ❑ Eastern -Surface Seal Installed by Repair Work Done ❑' 'Type df Pump H.P.' State Work Done Well Destruction ❑ Well Diameter. ' v Sealing Material (top 50') - Depth Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) G Installation will serve: Residence Commercial Other Number of living units: __/_ Number of bedrooms Character of soil to a depth of 3 feet: Water Water t ble depth .10 SEPTIC TANK -i< Type/Mfg .}- ,�SA Capacity }71�C� ..No. Coom� artments PKG. TREATMENT PLT. ❑ r Method•-of Disposal Distance to nearest: Well Founaation Property Line�_�� LEACHING LINE No. & Length of lines r` J�ze �'}�,Total length/size " !. FILTER BED ❑ Distance to nearest: Well !SZ2,- Foundation . Property Line SEEPAGE PITS U Depth Size -- -Number.- k SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F ` 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. - Homeowner ar ' nsed 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 p son such manner as to became ubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature j certifies-.the Ilowi : 1 certify that in the rZ nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali rnia." -1.4_•�_ � The applica mu all for all r in ins ions, omplete draw' erse side. Signe Title: nDate: �� 7� FOR DEPARTMENT USE ONLY C�x�xr +� Application Accepted by Date Area r✓ ICS 1 . Pit or Grout Inspection by 'V `= Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7_104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO At MOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. EH 13.24 IREV.10/83) EH 1126 I•J O-7 r