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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r, 1601 E. HAZELTON AVE., STOCKTON, CA /� d� Telephone {209} 466-6781 Lx9 �! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. y� Job Address " f City << Lot Size PM Owner's Name �� r5 �T. Address ! Phone Y D e _ Contractor Address - - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION GC_ 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 1 ❑ Industrial ❑ Open Bottom + 0 Manteca Dia. of Well Excavation �r Dia. of Well Casing �! bate 14-Gravel Pack L§�racy Type of Casing Specifications kWrPublic ❑ Other /DV`r�,f 1 Delta Depth of Grout Seat 5 f Type of Grou ro _ I I Irrigation 3WApprox. Depth I I Easter Surface Seal Installed by �"� � Repair Work Done ❑ Type of Pump s0 H.P. State Work D ne Well Destruction- ❑ Well Diameter Sealing Material ltop �� Depth .��]z Filler Material (Bel TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I rMSTRU01ON I I (No septic system permitted if public sewer is ,available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Nu"er of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PET- ❑ _ Method of Disposal , y Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. I& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line N11 4. SEEPAGE PITS 11 Depth Sizer 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.tie done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. 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, 1 shall employ persons subject to workman's-compensa- tion laws of California." The ap li ant must)call for all required inspections. Complete drawing on reverse side. Signed ��• Title: KJ 'Lt///j�� r Date: AV FOR DEPARTMENT USE ONLY Application Accepted by Date U t l /J Area O Pit or Grout Inspection Date Final Inspection by Date f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 141 )U Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Tc� ";,A4,2407/0 A*W1k/ FEE INFO AMOUNT OU/E, AMOUNT REMITTED RECEIVED BY ryDATE LPERMIT'NO. EH 114,28 21IFiEV.riK5l EH 3S bU b {{