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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � i t 1601 E. HAZELTON AVE.,•STOCKTON, CA Telephone (209) 466-6781 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 District. Job Address dJ City _r7lk Lot Size S' QiZ7 PM 'Own'er's FName_ ;4r-e Address_—f 6�A'1. - -Phone Contractor's Name�,�}/ �f!`� 5'Gf! License No. }.��y 7713 y.� Phone 4e TYPE OF WELL/PUMP: NEW WELL O ti'-N WELL REPLACEMENT-❑ DESTRUCTION ❑ ! i PUMP INSTALLATION. ❑ SYSTEM REPAIR".❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK [^`:. SEWER LINES DISPOSAL FLD. PROP. LINE : FOUNDATIONS" `- AGRICULTURE WELL OTHER'WELL PITS/SUMPS l INTENDED USE r TYPE OF WELL �PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ZDia. of Well Excavation Dia. of Well Casing �- ❑ Domestic/Private ❑ Gravel Packs �.O Tracy . Type of Casing Specifications ❑ Public ; ❑ Other . . y❑ Delta r Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Depth ❑ Eastern- Surface Seal Installed by i Repair Work Done • ❑ Type of Pump H.P. State Work Done wN r Well Destruction`' ❑ Well*Diameter I Sealing Material (top 50') __ T Depth { Filler Material (Below 501 -• - i TYPE OF SEPTIC WORK: NEW-INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION El-(No septic system permitted if public sewer isi - ./ available within 200 feet.) Installation will serve: Residence +' Commercial_ Other Number of living units: _/__ Numberiof bedrooms Character of soil to a depth of 3 feet: oyy Water table depth i SEPTIC TANK .❑"Type/Mfg,,.}_ "' "~ Capacity No. Compartments PKG. TREATMENT PLT.,❑ Method of Disposal i t Distance to nearest: Well Foundation Property Line ( i LEACHING LINE {❑ No. & Length of lines �.`-,Total,length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line t I SEEPAGE PITS Depth �t Lr -Size 15!!�c/oe .. Number SUMPS ❑ Distance tonearest: Well 04/4 Foundation /0 Property Line DISPOSAL PONDS Cl 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. 4 Home owner or licensed agent's_signature.certifies_the.following:—I-certify-that-in-the-performance-of the work-for-which this•permitas-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." r r The applicant ca11 for all required ins ctions, omplete drawing on reverse e. -' Signed Title: Date: 1 FOR DEPARTMENT USE ONLY Application-Accepted-by ..Date- --.Date- -Area.'. Pit or Grout Inspection by C Date 7h27h2H V Final Inspection by-/v` - Date k F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE PERMIT'NO. INFO- CASH n rf 1 -2sR1 13a(REV.16/83)