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y APPLICATION FOR PERMIT3�� SAN JOAQ'UIN LOCAL HEALTH DISTRICT J � 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 6 Local He@Ith District. - t�-c'�--� Job Address —d 7-Oi t ity 5_ Lot Size J PM O to 00 f Owner's Name .!,'�'rt Address rn� Phone Contractor= ~_ ddress �/��-� License No. � Phone r I' TYPE OF WELL/PUMP: NEW WELL.C1 WELL REPLACEMENT ❑ DESTRUCTION ❑ A PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K dt' 1_ DISTANCE TO NEAREST: SEPTIC TANK • SEWER LINES DISPOSAL FLD. PROP. LINE UU FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Privto ❑ Gravel Pack ClTracy Type of Casing Specifications M Public �', Ot ll Delta {depth of Grout SeaE Type of Grour — I i Irrigation r�� pprox, Depth l I Eastern Surface Seal Instal[ed by ^4 /,E:r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'I Depth Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIWADDITION I I DESTRUCTION l I (No septic system permitted if public sewef is available within 200 feet.) Installation will serve: Residence_ Commercial.,— Other' Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal 00 Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS i I Depth Size Number I SUMPS [_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D I hereby certify that t 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 Dt%trict- 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." 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 CaI fo fa." The applicant II If r all quired inspections. Complete drawing on reverse side- ZN Signed X Title: — Date: + "o OR DEPARTMENT USE ONLY Application Accepted by Date--�'-� Area Pit or Grout Inspection by Date Final Inspection by C _ Date r --G pa Additional Comments: f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFO FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT ND. +,EHr3-241REV.iinS) � �/ry0 Q^�t • EH 14-28 "� +1 w.w Ile. w �