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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVE® Telephone (209) 466-6781 N AR 0 8 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOA.OUIM C0t1s:3'TY 1 (Complete in Triplicate) PALIO HEALTi �.'..","1`13,.f'�,l!r}�� Application is hereby made to'the San Joaquin Local Health District for a permit to construct and/or install��JJbftai T�eS ♦f d! l 'akrp(iCdtion 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. j &1, � t Job Address .r�7j 5 L! City. Op Lot Size PM ai A/ft4 Owner's Name�/� _ _L_ Address Phone �� g r �� Contractor� / Address�]�� License No.'V Phone_ TYPE OF WELL/PUMP: NEW WEAL`;❑ 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 �+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom PC Manteca Dia. of Well Excavation Dia. of Well Casing l Domestic/Private El Gravel Pack } ❑ Tracy Type of Casing Specifications [7 Public F1 Other -,:C Delta Depth of Grout Seal Type of Grout _ I i Irrigation -Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done Jib Type of Pump, A L.� fi.P 1 State Work Dori Q� Well Destruction' ❑ Well Diameter Sealing Material (top 50141AX -A Depth _- __ -' Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION l I (No sop is system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial'_ Other 3' f, Number of living units: Number of bedrooms" Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Weirs" Foundation Property Line . U LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS F I I Depth Size tJ ' Number SUMPS - 0 Distance to nearest. Well Foundation Property Line —DISPOSAL PONDS—©—— --&4.-- 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."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 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu��stt call f r all required inspections. Complete drawing on reverse srd / y� Signed X �'l ----- Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 1 .. zm Date —�� rea Pit or Grout Inspection by Date Final Inspection Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 SH RECEIVED BY DATE PERMIT-NO. INFO �.EH 13- (REV.i/H 51 -C- EH 74-28Mc,,,,—. hI dtS 1 r J La