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APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA t n Telephone (209) 466-6781 Na W� PERMIT EXPIRES TYEAR 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. ! Job Address �V rr7 . �_r___ 4� C ,�Z Lot Size PM Owner's ame � Address Contra Addrestr +/ GF �� Licensel-N �/ Phony 8�y�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC IONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel vation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casing Specifications \, I'1 Public I7 OtherI� D Depth of Grout Seal Type of Grout I i Irrigation Approx. D 1 Eastern Surface Seal Installed by y - Repair Work Done 0 T ump H.P. State Work bone Well Destruction Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') y TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTIO'N<No septic system permitted if public sewer is available within 200 feet.I r Installation will serve: Residence _ Commercial_ Other V_ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK - ❑ Type/Mfg _ Cap_acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �[ F SEEPAGE PITS I 1 Depth Size Number .,....-.___ SUMPS ❑ Distance to.nearest: Well Foundation._- Property Line DISPOSAL PONDS Cl I hereby certify that t 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."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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all required in ctions. Complete drawing on rev 'da sre. Signe Title: - Date: F DEPA MENT�SENLY t Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection blA(lk Dated Additional Comments: _ 69wi ❑ Stk 466-6781 ❑ Lodi 69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE IN O AMOUNT DUE AMOUNT REMITTED CASHCK RECEIVED BY DATE PERMIT'NO. EH 11� + 3.24 1REV.tiny EH 14-28 '-S /�o 94 �.V jj