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i APPLICATION FOR PERMIT i yy UIN LOCAL HEALTH DISTRICT 1 SAN JOAn ] 7 1984 1601 E. HAZETON AVE., STOCKTON, CA h Telephone (209) 466-6781 SAN ,IDl',QUIN I_C•GAL �l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH :DISTRI�� (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. 1662 for weil/pump and the Rules and Regulations of the San Joaquin Local Health District. CAI 2) 6,C !IJ4N /V G^''et Z!5 II / City Lot Size PM Job Address J! i Lai z-_ Phone Owner's Name �� Address ' i ] / 1 – y Phone Contractor's Name �(Lf 1 License No. TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT El DESTRUCTION El PUMP INSTALLAT ON y SYSTEM REPAIR j� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DI5POSAL FLD. PROP. LINE I j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONDia. T li of Well Casing O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of CasingSpecifications Domestic/Private ❑ Gravel Pack ❑ Tracy YP 1 O Public El Other _ El Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ astern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction Ll Well Diameter Sealing Material [top 50') + Md Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) ` Installation will serve: Residence— Commercial_ Other , ! Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ❑ Type/Mfg Capacity No. Compartments SEPTIC TANK �j �.; Method of Disposal PKG. TREATMENT PLT. ❑ I i� Distance to nearest: Well Foundation Property Line ; Property LEACHING LINE ❑ No. & Length of lines Total lengthlsi FILTER BED ❑ Distance to nearest: Well Foundation PropeLine SEEPAGE PITS ❑ Depth Size Number ;SUMPS ❑ Distance to nearest: Well 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 1 rules and regulations of the San Joaquin Local Health District. ertify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I c employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature j 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." The applicant_5W call for 9ki required inspections.. Cam late drawing oon}reve;7,side. A::�lAffs j 1 Title: v Date: i Signed j F R DEPARTMENT USE ONLY Application Accepted by Date -/ p Area ( i Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I it DK EI ffFEDUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT"NO. F yc6+EH 1324(REV.10!331 I EM 14-26