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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Qps�c�ry Z 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 d the Rules and Regulations of a San Joaquin Local Health District. �73 C -,��C � �;^__ r n� rvr-, Job Address S G'r/ �' f f +�IA� Lot Size"' ! Pty Owner's Name / G :21 Vff-v'IXI.5 P Phone 3 5rol Z IT Contractor's Nam v License No. T phon /z TYPE"OF WELL/PUMP:' NEW WELL lid' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI'ON, E -- '` SYSTEM,REPAIR C] OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK A6 —SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N i. ❑ Industrial $9,Vpen Bottom ❑ Manteca --- Dia. of Well Excavatiq z d Dia. of,Well Casing Qy0 J�"t3aT4festic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificationsd ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type rout W ❑ Irrigation ff-A-Tipprox. Depth astern rface Seal Installed by (+ Repair Work Done ❑ Type of Pump S H.P. State Work Done IVn1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms mm� Character of soil to a depth of 3 feet: Water table depth l� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: 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: Well Foundation Property Line l 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:"1 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 m st call for all required inspections. ompleta drawing on reverse side. r. Signed /LJ�� Title: Date: f FOR DEPARTMENT USE ONLY Application Accepted by Date AreaW Pit or rout I spection by ji��Date inal Inspection by DateO 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 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 1REV.10/83] EH 14-28 3 Q�O