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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 II Local Health District.• t Job Address _ 1'I l —Y i� � D CityLot Size 494�a PM. I Owner's Name 1 + •_ I _ Address _.111-1 Phone Contractor's Name 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 WEELI OTHER WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11Domestic/Private El Gravel Pack 10 Tracy Type of Casing Specifications.:; —� b - - . El Public ❑ Other ❑ Delta Depth of Grout Seal ' Type-of-Gio[it Y ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ElType of Pump H.P. -State Work Done l Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION'❑ (No septic system permitted if public sewer is /available within 200 feet.) I� Installation will serve: Residence Commercial_ Other , ;,I. 11" Number of Irving units: Number of bedrooms Y yr Character of soil to a depthh f 3 feet: f�A,d,A$/ i� Water table depth SEPTIC TANK f!d' Type/Mfg Ce —per- Cap cikzw No. Compartments 7� l PKG. TREATMENT PLT. ❑ tr ± Method of Disposal Distance to nearest:,;,', Well Foundation !0 ` Property Line -349 ` *y �r LEACHING LINE No. & Length of lines Z '-40 � Total length/size FILTER BED El Distance to nearest: Well 7.00 r Foundation 7-J Property Line SEEPAGE PITS ❑ Depth 1 Z Size Number 1 -/ r ;SUMPS L�' Distance to nearest: Well�7 D' Foundation� Property Line --=__=dISP}SAL 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, 1 shall not a 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- tionflaws of California." s The pplicant must call for all required inspections. Complete drawing on reverse side. s v . Signed X_ Title: � - Date: OR DEPARTMENT USE ONLY Application Accepted by - _ Date?_ 5'(' Area d T �Prtirout Inspectionby to -._yf° -`2' Final Inspection by e.1••= n ..Data� I �_�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE , AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`No. INFO + EH 13-24(REV.10/83) �4-7/,� � S EH 14-26 , I