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Ir' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 T q-q/ ��'� �errc� City Lot Size PM Owner's Name Address ZJe 9 /p Contractor s Address 4icense No. o�Qo 3— Phone Tf O TYPE OF WELL/PUMP:V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINEL FOUNDATION AGRICULTURE WELL OTHER WELL-22-L- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1(3 N Domestic/Private D4 Gravel Pack X Tracy Type of Casing loy(fl Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 161D Type of Gr ut ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 fo0� Depth C5� Filler Material (Below 501 TYR OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation w1 e: Residence_ Commercial_ Other 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 PKG. TREATMENT PLT. ❑ Foun a Method of Disposal STV[ Distance to nearest: Well Property Line LEACHING LINE ❑ No. & Length of lines Total length FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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."Contractors 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 muft call for all require inspectic s. Complete rawing on r verse side. Signed Title: Date: 7 OR DEPARTMENT US NLY Application Accepted by Date =21 Area A)�> Pit or Grout Inspection by -- '"� Date�� Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED K FI RECEIVED BY DATE PERMIT NO. INFO �y + EH 13-24(REv.t/65) f y� EH 14-28