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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209).466-15781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED _ .-.... . (Comple'le 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. _,71 L , ! { / Job Address r 'r r City Lot Size PM_ I [ � .C Z Owner's Name L-.[�//✓0 ��"Address `� Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: t t NEW WELL ❑ WELL REPLACEMENT ❑ -; "DESTRUCTION ❑ PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by L t " Repair Work Done ❑ Type of Pump H.P. State,Work Done ,r Well Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence— Commercial A Other 4 Number of living units:' Number of bedrooms iU•U Character of soil to a depth;of 3 feet: _ _ __...-..........._— Water table depth SEPTIC TANK ❑ :Type/Mfg Capacity .No. Compartments - —� PKG. TREATMENT PLT. ❑ Method of Disposal`. , Distance to nearest: Well "'F6uridatldh"" "' "Property Line LEACHING LINE ❑ No. & Length of lines "�� Total length/size 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 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 must call for all req inspections. C plate drawing on reverse side. �-- Signed Title: Date: Z/ FOR DEPARTMEN SE ONLY k Application Accepted byrT Date Area 0 Pit or Grout Inspection by - Date- inal Inspection by .aDate itional Comments: �tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 x ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental.-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 c � IEEENFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT"NO. +EH 13.24(REV.10/83) EH 1F28 l '1/—