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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMfT,EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) t Application is hopeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is Mr 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. , �Ij W6 I Job Address City Lot Size Pm Owner's Name A ess �� Phone Contractor Address Lise No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL�'l7RE WELL OTHER-L7UELL PiTSISUMPS"_'� „"° INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 In�astrial ❑ Open Bottom O'Manteca Dia. of Well Excavation Dia. of Well Casing i Domestic/Private ❑ Gravel Pack a-frIly Type of Casing Specifications 171 Public f=1 Other ❑ Delta Depth of Grout Seal Type of Grout--. I I Irrigation --Approx. Depth l Eastern S ace Seal Installed by \ Repair Work Done ❑ Type of Pump H.P. State Work Done F Well Destruction ❑ Well Diameter Sealing Material (top 50') Ll V ` Depth Filler Material (Below 501 \V� '�'T-YPE'OF SEPTIC WORK:-r NEW INSTALLATION 111 REPAIR/ADDITION I-]„DESTRUCTION I-)jNo_septic system permitted if public sewer is 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: yya e SEPTIC TANK ❑ Type/Mfg Capacity -_ P is PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Pro' inq a 1 0-1 C. } 1IH1 LEACHING LINE ❑ No. & Length of lines Total lefio AQ FILTER BED ElDistance to nearest: Well Foundation urn ISION EN v 159. I SEEPAGE PITS JJ Depth Size Number =-SUMPS- =- -- ;= L1- Distance to nearest: - "^Well --* -^ iFoundatibn - Property-Line E 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: "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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date-, OR DEPARTMENT USE ONLY Application'Accepted by DateQ Area Pit or Grout Inspection by bateto Final Inspection byDate « S 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,.-Bax 2009, Stk., CA 95201 IFEE AMOUNT DUE AMOUNT REMITTED H R CEIVED BY O TE PERMIT'NO. L +.•EH 13-24 MEV.1/n!,) 17 EH 14