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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT jS IN. r — AVE. STOCKTON CA VV 1601 E. HAZE I ON , Telephone (209) 466-6781 SEP 2 2 X88 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVir40NMEN�TA�L`�HE�A�LTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereirPE"1406-ENbypticalion 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. 11 LlC Job Address City Lot Size PM Owner's Name �L_ _ , Address Phone Address OCiceflse NoPhone5 Contractor ' TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION . SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial D Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing PomesticlPrivate ❑ Gravel Pack D Tracy Type of Casing Specifications Fel Public FI Other I-1 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump.�� -_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms b Character of soil to a depth of 3 feet: Y Water table depth SEPTIC TANK LJ Type/Mfg �~ - -Capacity No..Compartments PKG. TREATMENT PLT. D t 1 Method of Disposal } 'Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS 1 0 Distance to nearest: Well Foundation Property Line 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 applica�n. r ups for ail required inspections. Complete drawing on everse side. Signed XTitle: Date:'2 Z _ FOR DEPARTMENT.USE ONLY j Application Accepted by _ Date rea [. Pit or Grout Inspection by Date Final Inspection b Dawo Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 1}21 fREV.1/957 ^� EH 14-2a