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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT w, 1601 E. HAZEL I ON 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,whh 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. n Job Address ^c.� City Lot Size !.Z 1 PM Owner's Nam !e Address 73-0 , I hone Contractor's Nam License No. � Cp ~ ' TYPE OF WELL/PUMP; �NEyy WEL-L O -- �^ Phone Q -- WELL-WELL - DESTRUCTION-C7.-.-� - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ., OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,DISPOSAL FLD. PROP. LINE �r FOUNDATION AGRICULTURE WELL-' R OTHER WELL- _ PITS/SUMPS INTENDED USE - TYPE-OF WELL PROBLEM AREA__CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dial. of Well Excavation W EJ Domestic/Private - Dia. of Well Casing .I ❑ Gravel Pack ❑ Tracy Type of Casing J itl r� r `' ❑ Publicv Specifications 4 ❑ Other ❑ Delta 't t ' - Depth of Grout Seal = f ti ❑ Irrigation --Approx. Depth ❑ Eastern �' Typerof Grout. Surface Seal Installed by Repair Work Done ❑ Type of Pump Tn H. r State,Work Done Well Destruction ❑ Well Diameter ' Sealing Material-(top,50') Depth Iler Material (Below 50'1- TYPE OF SEPTIC WORK: NEWINS,T/ALLATION E3REPAI ADDITION ❑ DESTRUCTION LJ Wo septic system permitted if public sewer is i Installation will serve: Residence F --- -rte=-�-� available within r200 feet./ r Commercial— Other Number of living units; —I— Number of Pedroonis 3 Character of soil to a depth of 3 feet: {" It SEPTIC TANK ❑ T e/Mf Water'tabie depth a Type/Mfg Capacity / No'Compartments PKG. TREATMENT PLT. ❑ , Method of.Drsposal Distance to nearest: Well Foundation /Pr f } Prop�rtyr Line LEACHING LINE ❑ No. & Length of lines Toial Iengih/size FILTER BED ❑ Distance to nearest: WeFoundation f well Property Line SEEPAGE PITS Depth _ o�cs„_Size r r }' SUMPS Number ❑ Distance to nearest: Well 40r DISPOSAL PONDS E2Foundation�� 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, rules and regulations of the San Joaquin Local Health District. and 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 certifies the following:"I certify that in the performance of the work for which this permit is issued, tion laws of California." !shall employ persons subject to workman's compensa- The applicant ust call fo II r uired Inspections. Complete drawing on'reverse.si Signed Title: Date: ' !�. FO DEPARTMENT USE ONLY Application Accepted by Date Ll D Area Pit r Grout Inspection by Date. Final Inspection by � _ Date Additional Comments; `" """'—'T" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6305 Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 1324(REV.10/83) EH 14-28 / .