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APPLICATION FOR PERMIT aD SAN JOAQUIN LOCAL HEALTH DISTRICT ( 1601 E. HAZE T ON AVE., STOCKTON, CA �✓ Y Telephone {209) 466-6781 p . Sfp PERMIT EXPIRES 1'YEAR FROM DATE ISSUE 23 198 (Complete in Triplicate) p !V/l,r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work'f�i�reit��siti,. d. 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�{ +p21ly the San Joaquin Local Health District. Job Address T City Lot Size PM t Owner's Name ddress Phone /�'�G Q� A 02"— m /a!s Contractor t/ Address License No.z�s �Phone !i d 'jp8 M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .gestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern.., Surface Seal Installed by Repair Work Done ❑ Type of Pump 15a: H.P. Z �f State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 O I .Depth / 7� Filler Material i8elow 501 6 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia HEPAIR/ADDITION 1 1 DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑. Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal " Distance to nearest: — Well Foundation Property,Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest:14 Well Foundation Property Line SEEPAGE PITS C I Depth Size_ Number SUMPS Ll 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 rules and regulations of the San Joaquin Local Health District. 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, I shall employ persons subject to workman's compensa tion laws of California." The applicantmus tali for all re ui inspections. omplete drawing on reverse side. Signa Title: _ � aaG� Date: I FOR DEPARTMENT USE ONLY QI /A { Application Acceptedby ' ' ` Date ! . Areay _. Pit or Grout Inspection by Dwe Final Inspection by Date01 Additional Comments: ❑ 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 c FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH 13-24 IREV.t/x 51 EH 14-28