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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 ( f43 City Lot Size PM A A „w + Ell /r 7- - i--mac..._ _A- ----- -------------- Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table Characfer of soil fn +. Contractor's NameA&AkV JLic-ens..Ni ar i r__�..`i 62L01 % r, Phone ` TYPE OF WELL/PUMP: 60EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �C1SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I-On SEWER LINES DISPOSAL FLD..4Vf'9' PROP. LINE FOUNDATIONM —AGRICULTURE WELL - - -.OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Il ❑ Industrial Ll Open-Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private >e-G-avel Pack Tracy Type of Casing__ PiVcz _Specifications ❑ Public C1 Other ❑ Delta Depth of Grout Seal � .__ Ty a of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump — — H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') 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 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. ❑ ~r 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 IM11 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ `l Z I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquir M19@M,& �stpWialve;�qnd rules and regulations of the San Joaquin Local Health District. �pp I� 1, Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichrtk KYrWt'Vi s��i�kV, 1-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- tion laws of California." The applicant 4ust call for all rewire nspections. Co plate drawing on re M.d' Signed Title: Date: /Z 7 �` � OR DEPARTMENT U NLY Application Accepted by Date ' Area Pit or Grout Inspection by Date "/Z �`Final Inspe on by Date r Additional Commen ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 55-6385 Applicant'- Return all-copies to:Environmental Health Permit/Services 1601 E. Hazelton-Ave., P.O:Box 2009, Stk., CA.95201, INFO FEE AMOUNT DUE AMOU-{1NT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 1320(REV.10/83) ✓d tQ�3 7-12-fS V [� EH 1428 b