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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .a (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. Job Address 1 f0 F' 411.wu�Pr i City 5f"ti`rLti1t Size PM . . 00— Owner's Name �"'LM `� E Address P F. w y Phone r Contractor's Name Ccense No. O Phone Q _776 TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL E. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ._�p.lndustrial-_ . _,, —0.Open Bottom__ w. ,❑."Manteca..-_--.-Dia__of Wall Excavation. =!- -----v Dia.-of Well Casing, -•- -- -- XQomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other _❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Easternce Seal Installed by Repair Work bone El Type of Pump �� H.P. -7SurfaState Work Done 2WSTAfa" 1A)Well Destruction E3Well Diameter Sealing Material (tap 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑,' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial'-- Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal l 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines`' Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line C�' I SEEPAGE PITS ❑ Depth Size Number „ SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 . e-:d agent's,sign-atube certifies>the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any per �'in such manner a's-to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the fbi wi g:"1 cert" "that'in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C if ia.".1' The applican call for lire r d in ns. Com to drawing on reverse side. p Signed Title: r '�"" -- -.. Date: a F DEPARTMENT USE ONLY Application Accepted by Date �� Area, Pit or Grout Inspection by t Date final Inspection by e s Additional Comments: 1 — ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca W-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. INFO CASH r + EH 1324(REV.10/83) Q ' j EH 14-26 ,