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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 I� .rf omplete 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 I' Local Health District. 02 2 ^d 2— Job Job Address City Lot Size PM it Owner's Name i Address Phon Contractor 3 Address �(��lr1l/ �!v_ License No. Pon ✓i`/ TYPE OF WELL/PUMP: NEW WELL;9 WELL REPLACEMENT ❑ DESTRUCTION ❑ i. PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER`JJ, ocl. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE i FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavantiopn8s� Dia. of Well Casing T: Par f'KCS Specifications ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing_,. p (`l Public `II Ota er ❑ Delta Depth of Grout Seal _ AS __ Type of Grout ��cc i I i I Irrigation ;ZsApprox. Depth I 1 Eastern Surface Seal Installed by I� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ? Depth Filer Material (Below 501 — 4. t TYPE OF SEPTIC WORK: NEW INSTALLATION 17. REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:- Water table depth I NL SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments } PKG. TREATMENT PLT. 0 � Method of Disposal L Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size I y FILTER BED ❑ Distance to nearest: Well Foundation Property Line II R SEEPAGE PITS I l Depth Size Number 0 SUMPS 0 Distance to nearest: Well Foundation Property Line " 1 DISPOSAL PONDS ❑ I 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 r rules and regulations of the San Joaquin Local Health District" II 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 signature 4 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 laws of Califo ra." i The applicant call f all required inspecti s. Complete drawing on reverse side. I 1 Signed X Title: —aggDate: I� I FOR ART E SE ONLY II Application Accepted by Date ' AreaI p�� !1 Pit or Grout Inspection by Date .A Final Inspection by Date z i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 " II iFEEO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PER11T' 6. ' k + EH 13-24 EH 1J-2e IREV.i/x 5; /l) Ir t /) (i V v II ;G Il