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APPLICATION FOR PERMIT �r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA y - 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. n Job Address I `l � �'/ ' ! City 'eo of Size PM Owner's Name ale !dei A40tddress Phone 1 � k Contractor A X.z,_ &e;C —Add d <C License No.�� r � Phone TYPE OF WELL/PUMP: NEW WELL Q •. WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM ROTHER ❑ e DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES 'DISPOSAL FLD. PROP. LINE k r FOUNDATION AGRICULTURE WELL OTHER WELL? PITS/SUMPS { INTENDED USE TYPE OF WELL PF OBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑,_Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑'rTracy Type of Casing Specifications. a { M Public ❑ Other Cl Delta Depth of Grout Seal = € Type of Grout I l Irrigation t —.-Approx• Depth E I'Eastern Surface Seal Installed by ? + Repair Work Done 0 Type of Pump f H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 ._ l r t Depth # Filler Material !Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i-I REPAIR/ADDITION l 1 DESTRUCTION Mo septic system permitted if public sewer is r ' 3 available within 200 feet.) i Installation will serve: Residence— Commercial_ Other" Number of living units: Number of bedrooms t� Character of soil to a depth of 3 feet: j ` Water table depth `i k SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ a _ Method of Disposal Distance to nearest: ! Well ` M: Foundation t' Property Line i LEACHING LINE F ❑ No. & Length of lines v y - Total length/size FILTER BED f ❑ Distance to nearest: Well 1 F t Foundation Property Line SEEPAGE PITS r � 11 Depth � Size Number SUMPS r- # ❑ Distance to nearest: Well Foundation t Property Line DISPOSAL PONDS ❑ TM 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 thp'orformance of the work for which this permit is issued, I shall not employ any,pefson 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." , The applicant must call for all required in ctions. Complete drawing on reverse side. n Signed c Title: Date: F DEPARTMENT USE-ONLY Application Accepted by Date v� Area j Pit or Grout Inspection by Date Final Inspection by Dat100re/ Additional Comments: 1 ! ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO MOUNT DUE AMOUNT REMITTED CK =DATE RECEIVED BY ' PERMIT' 0. f{/� CASH _ + (REV.1i955 EH 1028 S•p V V �O