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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTO N AVE., STOCKTON, CA it Telephone (209) 466-6781 II PERMIT EXPIRES'lrYEAR 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. V, ::.I I ku�4 J0 Job Address 1 5�3 City Size PM Owner Y-V .s Name Address Phone Contractor Address 13,1 � d."l- r License No/(,2-)— 3 Phone)CRff3__C__ TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT 1-1 DESTRUCTION,LJ PUMP INSTALLATION El SYSTEM REPAIR .� OTHER 0 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 * Industrial El Open Boitom' 4 E3 Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private- _L Gravel Pack. -Tac'y"-'- Type-of Casing,---- t Specifications F-1 Public 0 Other ill 1-1 Delta Depth of Grout Seal Type of Grout Dffrigation --Approk. Depith C Eastern u ace Seal I 6talled by il Su Repair Work Done Type of Pump H.P. I State Work Done Well Destruction D Well Diameter Sealing Material-(top 501 ii Depth it Filler Material (Below 501__ -TYPE OF SEPTIC WORK: NEW INSTALLATION 171 REPAIR/ADDITION El :DESTRUCTION [D (No septic system permitted if public sewer is available within 200 feet.) VJ -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 SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ED r i Method of Disposal Distance'to nearest: Well Foundation Property Line T LEACHING LINE El No. & Length of lines Total length/size FILTER BED D Distanceto nearest: Well Foundation Property Line SEEPAGE PITS D Depth Size Number. SUMPS Ll Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS E I hereby certify that I have prepared this application and that the work will be dond'in;'accordance with San Joaquin county ordinances, state laws, and 'iLor rules and regulations of the San Joaquin -al 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." Contractorrs 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 woikman's compensa- tion laws of California.' The applicant must call for all required inspections. Complete drawing on reverse side. -3 Signed X Title: Date:' FOR IDEPARTME USE'ONLY Application Accepted by /AAA,,A Date Area Pit or Grout Inspection by Date Final Inspection by Date � �_2-" Additional Comments: 0 Stk 466-6781 El Lodi 369-3621 C1 Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servicei 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY!. DATE PERMIT`NO.' INFO CASH EH 13-24(REV,1/'B 5) 7A L - 6/- EH W26 p