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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MII (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 7 ev- City Lot Size PM II Owner's Name Address Phone 7 6 Contractor's Name _ � License No. �� _ Phone IS 4/—'J ! 3 P TYPE OF WELL/PUMP` NEW WE RX0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 41 SEWER LINES oe- DISPOSAL FLD.L5 PROP. NE , 1 FOUNDATION 10 10 AGRICULTURE WELL .- OTHER WELL T_-PITS/SUMPS-L-570 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION q ❑ industrial rOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q � Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications I ❑ Pu61ic "p Other ]-pelta � � Depth of Groui Seal Type of Grout 13 D Irrigation --Approx. Depth El Eastern Surface Seal Installed by Repair W6rk Done '❑ -Type of Pump H.P. State Work done Well 6estruction ❑ Well Diameter Sealing Material (top 1 —" I Depth Filler Material (Below 501 J TYPE!OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LI—DESTRUCTION ❑ (No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence_ Commercial--:, Other rr1 Number of living units: Number of bedrooms 1 Chaiacter of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ /00, Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS ❑ Depth 4" Size Number SUMPS ❑ Distance to nearest: Well oundatian .Proparty_ ine DISPOSAL'PONDS.- ❑ h.. I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin couhty 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 followi :"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 IaWs of Calif The applicant uire nspec' Complete drawing on re rse ide. ` Signed Title: .� u Date: FOR DEPARTMENT USE ONLY Applicatio ccepted by -1Z G Date Area Pit or 5-o nspection by Date �S Final Inspection by Date 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 AMOUNF REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH u + EH 13-20(REV:10/83) .5 � EH 1426 II