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APPLICATION FOR PERMIT ! - SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) `F 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. � t n /oax /34 PM Joh Address C'.C.4•�s� E J7y� City Ti(� Lot Size Owner's Name C1e (r cr'No Address Gly C�.472.4lG Phone �� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR F) OTHER El I DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i' ❑ Industrial ❑ Open-Bottom IO-Manteca---- Dia: of Well Excavation- Dia. of Well Casing EE ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — I * Public f7 Other f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l 1 Eastern Surface Seal Installed by = Repair Work Done ❑ Type of Pump H.P. State Work Done E Well Destruction k ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION I I DESTRUCTION No septic system permitted if public sewer is \ a ailable within 200 feet.) t Installation will serve: Residence— Commercial_ Other Number of living units: Number I of bedrooms F Water table depth v Character of soil to a depth of 3 feet: SEPTiC'TANK ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE 0 No. & Length.of lines — ..-.- Total length/size = I� FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 - �r SEEPAGE PITS I'i Depth Size Number k li SUMPS L1 Distance to nearest: Well Foundation Property 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 I� rules and regulations of the San Joaquin Local Health District. fy that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certi 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, I shall employ persons subject to workman's compensa- tion laws of California."-' The applicant mu t call for all required inspections. Complete drawing on reverse side. I Signed X —"--� Title: D t� N� Date: d FOR DEPARTMENT USE ONLY Application Accepted by r Date 1 Area 1,... 4 Pit or Grout Inspection by Date Final inspection_by Data II ;l Additional Comments: II ❑ 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 v , II FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �i.EH 13-24(BLV.1/"51 EH 14-28 h�