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4APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {219) 466-6781 PERMIT" EXPIRES 'I YEAR FROM DATE ISSUED .w _ iComplete 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 m 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, 407--; Z` / 42, r Ad i ,9�� A✓�'1,E 4C l6 n City Lot Size PM y„_ _�_......_... job c ress ..___....... __ Owner's Name ._ _%%fZ� __ Address ��.._ lGa�� Phone � _e!._ Contractor, .._liJr ! Addrass ��i License Nor Phone:J TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT 0 DESTRUCTION (:::1 PUMP INSTALLATION C; SYSTEM REPAIR r] OTHER 1] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _... .__ DISPOSAL FLO. PROP. LINE .... __.... ._........_ FOUNDATION .__ _ __ AGRICULTURE WELL OTHER WELL--- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS __ -------- 1] __.__1: Industrial C] Open Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications Piibiic (_I Other r""l Dena Depth of Grout Seal _ _, _ Type of Grout..._,.........-- Inigation _...__. Approx. Depth I I Eastern Surface Seal Installed by. Repair Work Clone Ll Type of Pump _. _ H.P. _ _.___ State Work Done Well Destruction t.:.1 Well Diameter _. Sealing Material (top 501 Depth Filler Material" jBelow 54'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIRlADDITION f i DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ..__Commercial _ Other _ ___ Number of living units: _J.,_._ Number of bedrooms 1 . Character of soil_ to a depth of 3 feet: _.. Water table depth SEPTIC TANK I::] Typi/Mig Capacity_. � No. Compartments PKG. TREATMENT PLT. f:l 7" Method of Disposal Distance to nearest: WBii ..f _ Foundation ! .Property Line LEACHING LINE No. $ Length of lines e Total length/size.. _. FILTER BED C:.] Distance to nearest: Well .Z1'_�Foundation Property Line ' SEEPAGE PITS ' Depth Size _ _. Number. SUMPS l.:] Distance to nearest. Well /_ irFboridwion �...�d�?"f" Property Line A . . ..�. � DISPOSAL PONDS I I hereby certify that i have prepared this application and that the work rorill be done in accordance with San Joaquin county ordinances, state Taws, and rules and regulations of the San Joaquin Local Health Oi-trict. 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 foil which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California.,' The applicant must call for all/equi%d inspections, Complete drawing on reverse side. Signed Title:.._ WDale: FOR DEPARTMENT USE ONLY Application Accepted by Data __ Area Pit or Grout Inspection by ��, g-,.J,�. , Date� 1 Final Inspection by� � ' �.�j'iDate ' 1 Additional Comments: ;,J Sik 456.6781 0 Lodi 369.3621 0 Manteca 823-7104 Ci Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boat 2409, Stk., CA 95241 EH 13.2! 1REV. Err 1426 FEE INft7 AM43lJNT DUE 'ANt4T REMITTEDCASH RECEIVED BY _ BATE PERM jT' Nb. C -I