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APPLICATION FOR PERMIT 1✓ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE6I 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 R s and Regulationsof San Joaquin Local Health District. ® 4 F Job Address v "O A,In' City /" Lot SizeAn -71 PM Owner's Name w �"`' Phone G/ -7/— ? k6 Contractor's Name C v License No. Ll Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ ( SYSTEM REP�IR ❑ OTHER Qt DISTANCE TO NEAREST: SEPTIC TANK/0 O U SEWER LINES /00 O a� DISPOSAL FLD�0 PROP. LINE FOUNDATION AGRICULTURE WELL i OTHER WELL PITS/SUMPS _ INTENDED USE TYP ELL PROBLEM AREA CONSTRUCTION SPECIFlgkTlflko ir ❑ Industrial Erl5pen Bottom I--] Manteca Dia. of Well Excavation Dia. of Well Casing L1 Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing Specifications ❑ Pu ❑ Other ❑ Delta Depth of Grout Seal Type of Grout rngation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done A Well Destruction ❑ Well Diameter Sealing Material (top 501 ,9 Depth Filler Material (Below 501 V) ,TYPE OF SEPTJC WORK:— NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) < 1,stallation will serve: Residence— Commercial— Other Z Number of living units: Number of bedrooms CRaraater of soil to a depth of 3 feet: Water table depth SEPTJC TANK ❑ Type/Mfg Capacity_ ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Q No. & Length of lines Total-length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 0 :y Depth Size Number SUMPS ' ❑ 'Distance tti nearest: Well Foundation Property Liner- DISPOSAL PONDS ❑ 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. Home owner or licensed agent's sign ifies 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 to bec bject tow man's compensation laws of California."Contractors hiring or sub contracting signature certifies the following:-'I certify Awnhe rm of,t ork for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif ni The applicant for I rect s: ate yawing on re side �A �� Signed Title: (`' Date: UP FOR DEPART NT USE ONLY Application Accepted by Date —3—?J-"Are a Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 CK RECEIVED BY DATE PERMIT"NO. INFO CASH +EH 13-24(REV.10/93) 6 EH 14-26 / � S—s O i