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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone Q091 466-6781 ' PERMIT EXPIRES 1 YEAR 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. �+ Job Address 5 !• L City � 10pot Size PM Owner's Name ` F77-- 3 Address Phone Contractor's Name a7v ao arrk License No. o OF OP - Phone TYPE OF WELL/PUMP,: NEW WELL ❑ lhlELL-REPLACEMENT—O--�.�---- �--DESTIRUCTIOIV�❑- _. ,.� PUMP INSTALLATION LJ 1 SYSTEM REPAIR ❑ OTHER ❑ i i DI STAN CEPTO`NEARE�ST: SEPTIC TANK SEWER}LINES,?'`_, ♦ DISPOSAL FLD. PROP. LINE' I FOUNDATION I AGRIC17CTURE-WEtL7—"—"-`OTHER WELL PITS/SUMPS f INTENDED USE j TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, , ❑ Industrial j ❑ Open Bottom ❑ Manteca, Dia. of Well Excavation Dib_of Well Casing ❑ Domestic/Private ❑ Gravel Pack El T; Type of Casing - Specifications ❑ Public ❑ Other ❑ Delta f� Depth of Grout Seal's 1 Type of Grout O Irrigation ___Approx. Depth Q Eastern Surface Seal Installed by 1 U Repair Work Done ❑ Type of Pump H.P. i t State Work Done Well Destruction ❑ Well Diameter Sealing Material (top EZ') Depth i Filler iMaterial (Belo 50') i 1 TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITIO ,❑_DESTRUCTION.-ID-Mo septic system permitted if public sewer is I 1 available within 200 feet.) ' 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 1 Capacity f No. Compartments PKG. TREATMENT PLT. ❑ V Method of Disposal d Distance to nearest: Well Foundation i Property Line LEACHING LINENo. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Dth e 2 P Size � _ Number SUMPS ❑ Distance to nearest: Well Foundations' Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sah Joaquin cour<iY'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 cer*y 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the pe ormance of the work for vvhioh•this-permit-is•issued;-I shall ernploy persons subject to workman's compensa- tion laws of California." ' s The applicant must call fo required . etions�Complete cawing on reverse side. Signed ` `ter-°� --Title: -"- :�.�1, Date:""�G FOR DEPARTMENT USE ONLY --` Application Accepted b Y� ,r , � Z r " PP P y __ __ , Date x �Ar Pit or Grout Inspection by Date Final Inspection by Additional Comments: 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. t EH 1324(REV.10183i EH 1x26 ♦ �C t9 J