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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR 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 6 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. City Job Address Lot Size PM � ---� ��p �^ e I��d 7 P+U�1/� A �fN �[_ Phon9 0 7 a 7 Owner's Name ddress .�y � Phone 0 Contractor 9 dress zP'�i �+�� License Na, ( TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ s INTENDED USE to TYPE OF WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS � ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Casi of Type n Specifications- XDomestic/Private ❑ Gravel Pack LJ Tracy �lV Tracy 9 M Public ❑ Other n Delta Depth of Grout Seal Type of Grout G 1 i Irrigation 4WA-4prox. Depth t I Eastern Surface Seal Installed by - -;. Repair Woik Done L1 Type of Pump H.P. —a State Work Dane Well Destruction ❑ Well Diameter — Sealing Material (top 501 - ° Depth Filler Material (Below 50.1 - TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION E I DESTRUCTION € I (No septic system permitted if public sewer is y. available within 200 feet.) r 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 r SEPTIC TANK LlType/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 'Foundation - Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I 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.-..�t..�� :. 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 California." The applicantIl for all r u ed inspect 9 s. Complete drawing on reverse side. Signed X Title.'..w� �� Date: FOR DEPARTMENT USE ONLY II ` Application Accepted by ,Cy ' Date �'I ' V Area Pit or Grout inspection by `�-� s� Date .7p Final Inspection by Data Additional Comments: ❑ Stk 466-6781 E 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 90-- 1Jq5 +.EH 13-24 1REV.i/K 51 i EH 14-29