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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON 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 c-��':•7 4e z9/a City Lot Size PM Owner's Name 'v [- 4V �''_ Addres. Phone Contractor { Address License No. ~' 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 Well Excavation o Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f M Public F] Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. f' State Work Done -_ Well Destruction ❑ Well Diameter Sealing Material (top 50')//` Depth Filler Material (Below 50') ! TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION M DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Re'dence= Commercial then ' Number of living units: r 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. ❑ ' y Method of Disposal Distance to nearest Well_7Y Foundation Property Line LEACHING LINE o. & Leng[h of lines z dotal length/size f FILTER BED ❑ Distance to neares�: Well Foundation Property Line 6 d'r^ SEEPAGE PITS I 1/Depth Size x� Number SUMPS ❑ Distance to nearest: Well Z026 Foundation- Property Line 347 ; 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." { 1r F The applicant mun ca11 for all required i pspect'ons. Complete drawing an reverse side. i { r Signed X Title: .. _ --• Date: A 0 'e 1 FO PARTMENT USE ONLY s I -. Application Accepted by - - 'Date""' "# j ''k Area Pit or Grout Ins '- _ _ � � r � /Inspection by by Date Final Inspection by 4 Date/6� Additional Comments: 1 ❑ Stk 466-6781 ❑ 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 s TT Y 'INFO AMOUNT DUES-- AMOUNT REMITTED.. -- CASH f'" -REGEIVED BY DATE — PERMiT NO. •,EH13.24IREV.1/85l ��/ !V ! f��]� EH 14-28 o� f/ i `ZJ{tel