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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 67S 1801 E. HAZEL T ON AVE., STOCKTON, CA n pfi Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I i (Complete in Triplicate) 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, Job Address �- City Lot Size 157a x PM Owner's Name Address _ Phone Contractor { dress License No.:15]�F 16 3 Phone Z 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca --- Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications "1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout----- 1 rout -1 1 Irrigation __--Approx. Depth l I Eastern Surface Seal Installed by - 0 f1 Repair Work Done ❑ Type of Pump H-P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIONFI I DESTRUCTION {No septic system permitted if public sewer is g ailable within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth 7 SEPTIC TANK ❑ Type/Mfg Capacity No.{Comps ments F V PKG.,TREATMENT PLT. ❑ Method of..Disposak Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size x FILTER BED ❑ Distance to nearest: Well Foundation Property Line. SEEPAGE PITS i I Depth Size __ Number �- SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 DiMrict. 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 applicantmustcall for all r quired&nc Signed Xns. Complete drawing on reverse side. - /yritQ__ Title: � 1�- �+ �-� Date:. G� , (� FOR DEPARTMENT USE ONLY t Application Accepted by "' L Date ^ res Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q 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 !f K H RECEIVED 6Y DATE PERMIT'NO. ��/r� +.EH -241REV.1iw 51 )NFO �I 1 f A� I _' 14 EH 14-2a 1 111 V