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R APPLICATION FOR PERMIT r . SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE T ON AVE., STOCKTON, CA A�A Telephone (209) 466-6781 YJ 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 [!/ City �ot Size q I K 13 D_ PM Owner's NameAddress _ J�1r1/�� Phone Contractor l 1^ I=- PtN1�_ ddress 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 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - 11 % ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private '' E] Gravel PLck ❑ Tracy Type of Casing Specifications ! ❑'Public i fT 1 A:7 El Other i EJ Delta— Depth of Grout Seal w Type of GrGut ❑ Irrigation -� pprox. Depth I ❑ Eastern Surface Seal Installed by Repair Work Done-» LJ Type Type of Pump H.P. State Work Done Well Destruction -❑ R Well-Diameter" Sealing Material atop 50'),k ' t I Depth' Filler Material (Below 50')r TYPE OF SEPTIC WORK: NEW INSTALLATION X_REPAIR/ADDITION L1DESTRUCTION 17Mo septic system permitted if public sewer is" [ 0 , ,f" \ ' :-, available within 200 feet.] Installation will serve: Residence_�—Commercial— Other Number of living units: J_ Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK .d ape/Mfg Capacity.._ No. Compartments v r PKG. TREATMENT PLT. ❑ yr Method of Disposal Distance to n rest: Wallfru�'-- Foundation //r7� Property Line I • -_ C LEACHING LINE CL--No, & Length of lines Total length/size tFILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i i CL-Bepth 4 � Number - � � P SUMPS *❑ Distange to Size �,nearest: Wella_ Foundation� Property Line t DISPOSAL PONDS ❑ x 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. Horne 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 I s of California,." The.applic ust call for IE req 'ed ins a tions Co late drawing on reverse side E' Signed - - V Title: Date: -� FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit`o�Giiiut 1rispection by M` "'" Date Final Inspection-by Date Additional Comments: ❑ 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 FEE CK 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERNIn"NO. t�EH 13-24(REV.1/95) zt EH 10.29 [