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c' APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 .E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED z { (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;.E �5/j/.�,s 2'ES--/,3,0 7 Job Address Aar -C � City of Size PM Owner's Name Address 1 . Phone Contractor Address ense No. C, � --Phone c� 'l a TYPE OF WELL/PUMP: V NEW WELL`( WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�lfU Jif PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u ❑ 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack 1 Tracy Type of Casing �e Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type"of aQ"Grout 1:1Irrigation --Approx. Depth C1Eastern Surface Seal Installed by o Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction � ❑ Well Diameter Sealing Material Itop 501 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.)i f', i Installation will serve: Residence Commercial, Other Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity' No. Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Y O Distance to nearest: Well Foundation Property Line f - ' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I 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 no k 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 Cali rnia." The app! an st call for all r quire spections. Complete drawing o reverse side - rF� Signed Title: Dater R DEPART NT USE ONL Application Accepted by Date AAea `r `%Y� 'f r �-; t A Pit or Grout Inspection y Date/ Final Inspection by Dat}y` .,T Additional Comments: R, ❑ 5tk 466-6781 ❑ Lodi; 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835385 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 s FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-241REV,1/85) v� i77D EH 14-28