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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 Local Health District. -71 Job Address " 3 City i Lot Size PM Owner's Name Address &�Ja/ a Phone m^2-;2- } Contr. ctorLlAddress ic'ui No. l3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT X DESTRUCTION g f1 GUC PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,: OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS' 2 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' rr I❑ Industrial ❑ Open Bottom ❑ Manteca 1 "Dia. of Well Excavation pia. of Well Casing Domestic/PrivateGravel Pack XTracY Type e of Casing- 1�_- S ' , r pecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal __ iLD ?. Type a rout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done- A l Well Destruction ❑ Well Diameter Sealing Material (top 50'1 a t' Depth .r Filler Material {Below 501 't E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) p 1 Installation will serve: Residence_ -Commercial_ Other Number of living units: Number,of"bedrooms �� Character of soil to a depth of 3 feet: f f �� z ` Water table depth ? SEPTIC TANK ❑ Type/Mfg ' >- Capacity No. Compartments i PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest: ; Well Foundation Properly Lin =� LEACHING LINE ❑ No. & Length of fines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS- ❑ Distance to nearest: Well < Foundation Property Line DISPOSAL PONDS ❑ 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. b 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 Cal'ornia." The applicant ._t call for all req r d inspe ions. Co plete rawing on reve side. { T T4 Signed vtu, ` Date: M F06D PARTMENT USE ONLY -7 k Application Accepted byf"f Date, --Y- 7 Area Pit or Grout inspection by Date�l Y-1,7-F7 Inspection by Date / Additional Comments: �t ,7-F • ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 :r FEE INFO AMOUNT DUE AM�yODUUNN�T REMITTED C/A�SH/75,. RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV,1/8!5 ///,_ C� J/' if / /O � EH 1428 GGG ///V 4 f(/+S(/ ti