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APPLICATION FOWPERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ! 4 on Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR TROM DATE ISSUED e(Complete in Triplicate) s l y 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'K.. �'. r f ,. . , r i Job Address r y.City - Lot Size AM_ Owner's Namer Address _ ��o0l Phone R_ Contractor's Name / 1�C�i'l�es�C eDLL C.J_icense No. 3 _ _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r � PUMP INSTALLATION ❑ � ��, SYSTEM REPAIR,.*�. . +� a, OTHER ❑ w �\ DISTANCE TO NEAREST:.SEPTIC TANK: SEWER LINES ` .. DISPOSAL FLD. -- PROP. LINE. FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t t ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation Dia, of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth /3 Eastern SuSeal Installed by Repair Work Done A Type of Pump a Wil"' H.P. State Work Done cwt Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public seweris available within 200 feet:) " 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 F SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _ Property Line " ' r 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: Well Foundation Property Line=_ F° 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 signature certifies the following: "d`ce`Tr ify that iri'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."Contractors hiring or,sub-contracting signature certifies the following:-"I certify that in the performance of the work for which this permit is issued, I shaH'err ploy persons'subject to workman's compensa- tion laws of California." The applica II for all required ins tions. omplet rawing on r else side. !,. . Signed Title: /�3+� Date': FOR DEPARTMENT USE ONLYOH Application Accepted by data 'a Area Pit or Grout Inspection b Date Final Inspection by �, f ry Dats :_-'?-�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104" ❑ Tracy 835-6385 it l Applicant- Return all copies to: Erivlronmental Health Permit/Services 1601 E..Hazelton-Ave,, P.O..Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE EPERMIT'NO.' + EH13-24(REV.10/83[ EH 14-26 c.. - ..