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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 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 /�f—// �` /= ' j'G� �, City . f 7 -�c�```Lot Size PM wner's Name G/" /a` 6 jc l `;" Address �' �f? n� ` N / `�/- Phone f Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOnOS " PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing El Domestic/Private El Gravel Pack racy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigationprox. Depth l I Eastern Surface Seal Installed by - Repair Work Done ype of Pump H.P. State Work Done Well Destruc ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIOI'(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 C l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a�1 PKG. TREATMENT PLT. ❑ Method of Disposal1 Distance to nearest: Well Foundation Property Line \ h� 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 Ll 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 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." T plicant must call for all required inspections. Complete drawing on reverse side. C�Sig�neadX Title: Qom^_ Date: 87 FOR DE RTMENT USE ONLY / J� Application Accepted by !N '� Date �, e12 -- Area _ Pit or Grout Inspection by.�1 Date Final Inspection by Date — Additional nal Comments: ❑ LF ?- �1 lJ odi 1 O Mante�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 K H" RECEIVED BY DATE PERMIT'NO. INFO ` + EH 3-24(REV.1/85) , 3' � GJ2 EH 1 / 7