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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.1 YEAR FROM DATE ISSUED e 2-2 x; ILi b,,'t- {Complete in Triplicate) T 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. -. ' .�• �.-. E s :,k w..xa. Fs ne City r� 1 Job Address + Size I PM Address Owner's Name �'V !� J l�P — Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ -PROP'L'INE FOUNDATION _ AGRICULTURE WELL 9T,HER-WELL}� PITS/SUMPS -yy_ - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCI`10N SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca��Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Specifications ❑ Public ❑ Oth"prox. ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done a _ r C Well Destruc' ❑ Weil Diameter T Sealing Material (top 50`1 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is 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: Capacity. No. SEPTIC TANK ❑ Type/MfgCompartments _ _ -� PKG. TREATMENT PLT. ElMethodof Disposal Distance to nearest: 'Well Foundation Property Line : k 100* 11 LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well - Foundation Property Line SEEPAGE PITS ElDepth Sze Number ' SUMPS ❑ Distance to nearest: Well Foundation§ Property Line DISPOSAL PONDS El I hereby certify that 1 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. r, J Home owner or licensed agent's signature certifies the following-'.11 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 applicant mus call for all required ins ctions. Complete rawing on reverse side. p "' Signed 'Title:' Date: — FOR DEPARTMENT USE ONLY t Application Accepted by Ate '?Stk., Area Pit or Grout Inspection by_ - Date _ ^ Final InspectiDate ,44ditional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835plicant- Return all copies to: Environmental Health Permit/Services 1601 £. Hazekon AY , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED AV RECEIVED BY DATE PERMIT"NO. INFO FV q e f� �f +Eli 1324[REV.10183! ;> — vV ;r' /t"�-- -4 g �,,Jl/� i EH 14-28