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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City �j/ t Size PM +� (� Owner's Name ddress � /7 4 ?d! M &TI1N Phon 0 ��7y,^ l KContractor / U _1,. I �1Qldress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ /LIN CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER DISPOSAL FLD. PROP. LINE hOUNDATION AGRICU OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR 13LEM A (A CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom Ll to Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications FI Public I� Other C-1 elta Depth of Grout Seal Type of Grout I Irrigation. _Approx. Depth I Eastern Surface Seal Installed by Repair Work Done CJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NFW INSTALLATIONREPAIRlADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is tt available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms e� i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity/DDD No. Compartments — PKG. TREATMENT PLT. ❑ Method of Disposal y Distance to nearest: Well 1 D/0� Foundation Property Line LEACHING LINE LAY hlo. & Length of lines F Total length/size U� FILTER BER LJDistance to nearest: Well 100 Foundation �f.__ Property Line SEEPAGE PITS I`1 —Depth Size _ Number _ SUMPS L� Distance to nearest: Well i cO Foundation _ �� Property Line W t— 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. ,ome 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." 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 st call for all requi i peclions. Complete drawing on reverse side. Signed X ��y4� r� ...�.�.[M6 Title: �� )f' . ._,.._ pate: R DEPARTMENT USE ONLY Application Accepted by Date �IN Area e Pit or Grout inspection by L&4dVi40at8 Final Inspection by L�Ck Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Envirohmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMII►TT'NO. + EH 13.24 MEV.iiH5) 7Q r� �4d rao !k EH 14-28