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APPLICATION FOR PERMIT ,SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 'i 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 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. I Job Address ## City r Lot Size PM A Owner's Name ! 0 1 Address '? �7,� �b4-a��r�t C7W0._ r�r Phone Contractor's Name License No. 62.L3 7-) PhonA b -r 4! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ W PUMP INSTALLATION Q'� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,S.PECIFICATIONS F ❑ Industrial ❑ Open Bottom .❑ Manteca Dia. of Well Exca_v;ibon Dia. of Well Casing i [?'Domestic/Private C1Gravel Pack EDTracy Type of Casingf Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal. TypeofGrout ❑ Irrigation _ Approx. Dep ❑ Eastern Surface Seal Installed bywy D f I Repair Work Done ❑ Type of Pump H.P. State Work Done&460 kkgr kj"st c Well Destruction ❑ Well Diameter Sealing Material {top 50'1 ' Depth � iti '� "Filler Material (Below5050'1 I 't ` TYPE OF SEPTIC WORK:-NEW"INSTALL'ATION`n—REPAIR ACDDITION'❑""DESTRUCTION r7`;No-septic systei6'permittedif-rublic sewer is available within 200 feet.► ! } Installation will serve: Residence—i Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a.depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. © Method of Disposal Distance to nearest:. Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth •°`Size Number SUMPS ❑ Distance to nearest:EE Well Foundation Property Line f'm `f DISPOSAL PONDS ❑ I i 1 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. tri+ 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 r employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature f 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." ' 1 � rThe applicant t c 11 for all !SAuired inspe ons Complete drawing on reverse side. i Signed X tZitle: i'� v Date: O t FOR DEPARTMENT USE ONLY Application Accepted by Date � Area i Pit or Grout Inspection by j Date Final Inspection by Date 1 i Additional Comments: I I ❑ Stir 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 ? Applicant- Return all pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 'CK 11 CASH -KO BY DATE PERMIT`NpO. � EC I + EH 13-24(A .10/83) "'+�' �1_N ��Q I EH 1428 i