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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA + Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 � � V � t� `� City a Lot Size PM Owner's Name /' a , S' dress 1A995 .Dm6kciC f Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR'❑ -`- { OTHER -El- 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 1 ❑ Industrial ❑ Open Bottom ❑ Manteca -- - Dia:-of-Well Excavation Dia- of Well Casing : ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l l`l Public Cl Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth 'I i Eastern Surface Seal Installed by _ t Repair Work Done ❑ Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is f 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED -•fl Distance to nearest: Well Foundation Property Line SEEPAGE PITS` }I I 'Depth ' ' Size _ Number \I SUMPS ❑ Distance to-nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certifl( 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 o�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 call for all requiiredj in"cgtiions. Complete drawing on reverse side. f Signed XJ � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by T Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Mant d 823-7104 ❑ Tracy 635-6385 l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEf AMOUNT- UEAMOUNT REMImmn— RECEiVEp BY DATE.. PERMIT•NO. ^ r INFO �j CAS 1 EH 13-24 IREV.t i H sl 14-2e r