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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? Az 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. 5 Job Address ` City + Lot Size PM '7 iwSUVN\ Owner's Name _ Address Phone_ Contractor's Nam; License No. 331 q 6Yl) Phone bd-_! «L Y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIIOyN�❑ SYSTEM REPAIR 9 OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK __• SEWER LINES iDISPOSAL:FLD.• PROP. LINE FOUNDATION AGRICULTURE WELL OTHLL ER WEi PITS/SUMPS INTENDED USE R TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ❑ Industrial ' El 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 ❑ Eastern Surface Sea! Installed,by ' Repair Work Done ❑ Type of Pump Sl� H.P. State Work Don OICC r Well Destruction 171 Well Diameter w Sealing Materiall'itop 501 ' Depth f Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living kunits:[ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK t ❑ Type/Mfg Capacity No. Compartments_ PKG. TREATMENT PLT. ❑ `�– r_ s.e � o Method of Disposal Distance to'riearest: Well ""'" Foundation Property Line - 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: Wel! Foundation Property Line DISPOSAL PONDS ❑ 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 I 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." i The applicant ust c II for all require 'n ctions. Complete drawing on rev rse side. Signed Title: �rC.e' Date: W I � FORDEPART NT USE ONLY p�• _ OC (� C/ Application Accepted by Datd" Area Pit or Grout Inspection by Date Final Inspection by Date S�-Z7S T — 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 o FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. INFO CASH + EH 13-24(REV.10/83) f�O ' � �' `�'� 1 25 } EH 1426