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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES TYEAR 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 Local Health District. III! / [f j r v` / i Job Address `LIV A , City �, Lot Size �by X} PM Owner's Name" �J A�dd�r'}ess �/ f f, Phone ` Contract c Address 1 ' �. �[�� License fVo.�275 2 � Phane��-�f® TYPE OF WELL/PUMP: �1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PIJ&P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEIPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE j!- FO,UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE-' TIYPE OF"WELL�- PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation vDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public n Other H Delta Depth of Grout Seal Type of Grout k 'I 1 Irrigation _�M�..Approx.,Depth ! I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.. State Work Done Well Destruction ❑ Well Diameter Sealing"Material (top 50') Depth" )ler Materia! 18elo 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAI 'ADDITION- " DESTRUCTION I I (No septic system permitted if public sewer is I' available within 200 feet.) i . Installation will serve: TFiesrdence— X� Com-me cia!�Other "•� - "` �� } !• " Number of living units: Al,. Number of be ooms- `] Character of soil to a"depth l�of 3 feet: s,. Water table depth SEPTIC TANK ❑ :,Type/Mfg Capacity No. Compartments+ PKG. TREATMENT�PLT. ❑ i� Method of Disposal" Distance to nearest: Well Foundation Property Line (721 it 4 LEACHING LINE X No. & Length of lines I Total length/size , FILTER BED ❑ ' 'stance to nearest' - Wel!S.:v_...__ Foundation Property Line SEEPAGE PITS I'i Depth Size r F �NrNumber SUMPS ❑ pistance to nearest: Well Foundation �" Property Line. { DISPOSAL PONDS` -0 IF I hereby certify that I have pr4ared this application and that the work will be done in accordance`wilh-San-Joaquin-county ordinances, state laws, and rules and regulations of the San Joaquin quin"Local Health District. Home owner or licensed agents signature-certifies the following: "I certify that in the performance,of the work f6r which this permit is issued, I shall not employ any person in such me'nner,as to.become subject to workman's compensation taws 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 Ildre uired inspections. Complete drawing on reverse sr y ?` Signed � Title: -- � Date: FOR"DEPARTMENT USE ONLY.' Application Accepted by — fate � Area Pit or Grout Inspection by TFinal inspection FiteJ Additional Comments: I� /SIV ❑ Stk 456-6781 Lodi 369-3621 Manteca 823-7104 ❑. tacy 835- Applicant - Return all copies t Environmental Health Permit/Services 1601 E..Hazelton Ave., P.D. Box 2W9,,Stk., CA 95201 i . FEE AM06NT DUE AMOUNT REMITTED CK INFO CASH N T RECEIVED BY DATE PERMIO. T N +.EH13-244REV.i/H51 EH 14-26 ia �i