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APPLICATION FOR PERMIT 1 lf SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA j Telephone (209) 466-6781 r� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Distri�,_4e6 Job Address City Lot Size 4 CJ' `�-- PM Owner's Name ��f`1 k& PC&/-Address ® � ` �T Phone i, Contracto Address.P. _ License No. si( L Phone 5 TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT 0 DESTRUCTION Ll � a """^'PUMP INSTALLATION -"""""""'"'"""SYSTEM REPAIR°❑ w •- OTHER ❑ / DISTANCE TO !NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL. FLO1 PROP. LINE FOUNDATION 'Z'�5 AGRICULTURE WELL OTHER WELL PITS/S UMPS_-92"O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Gf ❑ Industrial C1 Open Bottom ❑ Manteca Dia- of Well Excavatio Dia. of Well Casing v WOmestic/Private P ravel Pack ❑ Tracy Type of Casing Specifications t {1 Public ther ❑ Delta Depth of Grout Seal Ty of Grout i ! Irrigation ..Approx. Dept 1 1 Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H.P. State Work Done !f Well Destruction ❑ Well Diameter Sealing Material Stop 501 c� Depth ;� r —Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is �� available within 200 feet./ Instalfati will-serve: Re idence' Commercial— Other C� ! Number of living unr s. Number of bedrooms Character of soil to a depth of 3 feet: r ar table depth � lw SEPTIC TANK ❑ Type/Mfg No- Compartments PKG. TREATMENT PLT- ❑ e aquLsal /LU e Distance to nearest: Well Foun on_� _ Property Line r LEACHING LINE 10--'No. & Length of lines 'l4 Total length/size FILTER BED ❑ Distance to nearest: ell ) Foundation _bra Property Line_...__f• SEEPAGE PITS Dept ,7 Size [Q-, Number 1-3 SUMPS ❑ rstance to nearest: Well Foundation�/�'�— Property Line IS!� 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,l shall employ persons subject to workman's compensa- tion laws of California." The applican t call for all required sped s. Complete drawing o 'ver14 se sidle. ti Signed X Titre: __ 1 C Date: OR DEPARTMENT USE ONLY Application Accepted by ADate ",- Area Pit or Grout inspection by Date rPW-T? Final Inspection by .��J"r Date's CIO- 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 � 1•� FEE OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. 1f! r INFO CASH +.EH 13-24(REV.ri95r V91 0EH U-28 Q 'I /r.,_ �7 `