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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone {209) 466-6781 F A PERMIT EXPIRES 1 YEAR,FROM .DATE ISSUED (Corn lete in Tri ficate) 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 "SO y��,.,•• Q 04 ! yIV,C Ly / Q' �� kL � . - ,l� Ciri Lot Size , L¢ PM Job Address �C. 31)i� S Owner's Name �� Address _ Phone S 77 Contractor's Name License No. o 17— ! TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUC ION PUMP INSTALLATION ❑ SYSTEM REPAIR [1 OTHER ❑ �4 DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f E] Industrial E] Open Bottom [I Manteca :Dia.-of Well Excavation Dia. of WelGas" ing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ) ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type.of Grout — ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 501 Depth I Filler Material (Below 501 t r` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted ik?y. ic�r is } available within 200 feet.) Installation will serve: Residence—1 i ommercial_ Other Number of living units: Number'of bedrooms v 1 Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments PKG. TREATMENT PLT. ❑ ? Method of Disposal Distance tofnearest:' f Well Foundation Property Line 1 7° 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED "❑ Distance to:nearest: i Well /� Foundation—Property Line SEEPAGE PITS ❑ Depth r-T— Y 'Size j Number, SUMPS "❑' Distance to nearest: "',_'Well Foundation Property Line _ I DISPOSAL PONDS ❑ k 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 taws of California." Contractors 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 Cat'rfornia." The applicantII for all required inspections. Complete drawing on reverse side. k Signed XTitle: Data: t FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection byzoW. Date I F I Additional Comments: '. ❑ Stk 466-b761 ❑ Lodi 369-3621 C3 Manteca 623-7104 Tracy 835=6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NQ. INFO +EH 1344 EH 1426(REV.10/83)