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i " 5 G APPLICATION FOR PERMIT s i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 I 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. ri ' Job Address ZHA City V t Size PM ir� �",�A I 1�l Cs I Owner's Name Address �4 0 Phone ! 1140 Contractor's Name �—! License No. Phone TYPE OF WELL/PUMP: ,NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO;NEAREST: SEPTIC TANK —1V+ SEWER LINES DISPOSAL FLD. P�OP. LINE .r FOUNDATION AGRICULTURE WELL OTHER WELL—A--Q— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� 11 Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ;Domestic/Piivate L1Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public - Other ❑ Delta Depth of Grout Seal.__ Type of Grout ❑ Irrigation F ti ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done .t Well Destructi6n4; ❑ 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 r. Character of.soil to a depth of 3 feet: "° Water Sable depth SEPTIC TP NK .." `.❑=Type/Mfg ., "£ `� Capacity`:_"'."" �`"No.`Comparltments''' PKG. TREATMENT PLT. ❑ i' ! Method of Disposal I Distance to nearest: Well ` . Foundation _ _ Property Line ' LEACHING LINE ❑ No. & Length of lines ' < iit r .- Total,length/size FILTER BED ( El Distance to nearest: Well Foundat'ion711� Property Line f SEEPAGE PITS ❑ Depth I Size - ,:Number SUMPS ❑ Distance to nearest: Well '1 Foundation Property Line ° 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. 1 j Home owner or licensed agent's signature certifies the following:='1 cegfy that in the performance.of the work for which this permit is issued, I shall not employ any pe n in such manner as to become subject to workman's Compensation laws of California."/Contractor's hiring or sub-contracting signature { certifies the fol in r " fy that in the ormance of the work for Aich this permit is issued,I shall-employ persons subject to workman's compense 1 tion laws of C I ornia.' ; The applica t call a quire is ti ns. C {plete drawing.on..reverse side.�� I� Signed jj" Title: / ► Date: A f FOR DEPARTM,ENT USE ONLY . Application Accepted by Date Area V • .fir y''I~ Pit or Grout Inspection by Date 2 `� Fina1.Inspection by Date � ii � ► Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601,E.-Hazelton Ave,,-P.O: Box-206i),--Stk.—CA-952011 ITEE I AMOUNT DUE I AMOUNT REMITTED CK* RECEIVED BY DATE P6MIT'NO. i INFO CASH +EH 13-24(REV.10/83) EH 14-26