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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 TYEAR 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. I Job Address _.._ City Lot Size PM � �-✓CG�r z1.�.0�?. Owner's Name Address f�hone `� Contractor Phone Address License No. 41 7- " u f - - --�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPIZACEMENT ❑ DESTRUCTION JO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial El Open Bottom ❑ Manteca Dia. of Weli Excavation6 ti Dia. of Well Casing Domestic/Private ❑ Gravel Pack 5Q Tracy Type of Casing Specifications [-],Public n Other Cl Delta Depth of Grout Seal I Irrigation Type of Grout g" —_..Approx.-pepth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth -2- Filler Material (Below 50'x.., TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I f INo septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) - n Number of living units: Number of bedrooms "� r►f k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I j PKG. TREATMENT PLT. ❑ Method of Disposal -�- Distance to nearest: Well Foundation Property Line BEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest4ll WeFoundation �- Property Line SEEPAGE PITS I I .Depth Size Number G SUMPS ❑ Distance to nearest: Well Foundation1 DISPOSAL PONDS CI Property Line 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 Di$trict. Home owner or licensed agent's signature certifies the following: "f 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu 11 for all required i s ctions. Com to drawing on reverse side. Signed X Title: Date: AI FON EPARTMENT USE ONLY I Application Accepted by Date - Area Pit or Grout Inspection by Date Final Inspection by / Date ' Additional Comments: ''!�!9a Wel1 �1&d 7'v 1{1',So -Ir- fo t IF, fi ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 r❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 PP FEE MOUNT DUE AMOUNT REMITTED INF CKS��qq \j RECEIVED BY ] 1DATE 4 PER MIT'NO. +.EH 1324 IREV,r r 51 r 5.�� C�'"`�� `{�-'. � �"} '� 4 S� r tr� EH 14.26 _ ii