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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby mnry Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Cou Local Health District. Job Address . City Lot Size PM Address,?—�m Phan Owner's Name _ e-1LI) n 33 50 Contractor/rNz� Address_W0 License Nd; �/ Phone 997 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X -. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Il ❑ Industrial ❑ Open Bottom ❑ Manteca, � Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications [-I Public F1 Other ❑ Delta - Depth of Grout Seal Type of Grout I I Irrigation 4 ----Approx,.•Depth. I I Eastern sv,..,--j♦�Surface Seal-Installed-by ^- Repair Work Done L7 Type of Pump H.P. Y State Work Done € Well Destruction- ❑ Well Diameter Sealing Material (top 50') 4 F Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION I I (Nosbetic systithinem retitled if publiavac sewer Installation will serve: Residence Commercial_ Other 6 ti a (} 'Number of living units: Number of bedrooms {n i Character of soil to a depth of 3 feet: Water table depth V' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v'A i PKG. TREATMENT PLT. 11 Method of Disposal V! i Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size T F FILTER BED El Distance to nearest: Well Foundation Property Line I i SEEPAGE PITS I I Depth t Size Number 1 SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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'ktrict. 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 signator F certifies the following:111 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 must c for all required ins ctions, Complete drawing on revers ide. Signed Title: Date: FOR,DEPARTNIENT USE ONLY p Application Accepted by f Date r- � U Pit or Grout Inspection by Date Fina! Inspection by Date Additional Comments: E3Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 EJ Tracy 635 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 r INFO AMOUNT DUE AMj-6-, EMITT]/!71/ RECEIVED DATE Com//l PERMIT'NO. t. + EH 13-244REV.1/95) 3�- � � EH 14-2e