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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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 1!�e ,2 . 6 �y City s 7— Lot Size PM Owner's Name r ddress % a L b 1 ",4 _4'd Phone Q�3 i Contractor Addfess License No. Phone TYPE OF WP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Ni. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4% FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEDNUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial \ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public Ll Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation .-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Dane O Type of Pump H.P- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commercial .Other Number'of living units: Number of bedrooms 'r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg / - No. Compartments PKG. TREATMENT'PLT. CaMethod of Disposal Distance to neares Property Line LEACHING LINE ❑ No. & Length of f butll !t 12 _ Total length/size FILTER BED ` ' ❑ Distance to neare f (� Property Line SEEPAGE PITS -I I Depth 7 � , Number SUMPS �f. '*k Cl Distance to nearProperty Line DISPOSAL 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. y-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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. #F Signed X -e d Title: © Date: l I f g7 (J or I FOR DEPARTMENT USE ONLY t Application Accepted by �" _ Date —95—Area Pit or Grout Inspection by'�f Date Final Inspection by ,Date �J f Additional Comments: +"T �G�9NL�!`- -�B� / !.f�LY� 42A,A,, " 1�2 ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ racy 835-6385 �� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH 3241 E CK RECEIVED BY DATE PERMIT'NO. +. H! FIV.1/85Y 4 �S�b 3 67 �� EH 14-2a