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APPLICATION FOR PERMIT Meg SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� Z 1984 (Complete in Triplicate) SAQUIN Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h e �is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulationss oo� quip Local Health District. Job Address City WS Lot Size PM Owner's Name 1 t`�-uw� Address � ?�2.,.. �4'� i Phone I Da Q Contractor's Name nuc fr _ License NoA )'} 13 Phone b� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0" SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLD. PROP. LINE E FOUNbAT10N AGRICULTURWELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I?-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 00 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type:of Grout ❑ Irrigation --Approx. Dep h Eastern Su ace Seal Installed by Repair Work Done d Type of Pump H.P. Z State Work Dort Well Destruction ❑ Well-Diameter Sealing Material (top 501 Depth_ _ Filler Material (Below 501 ? TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION 11 DESTRUCTION 1-1 (Noseptic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence— Commercial_ Other ! OL Number of living units: Number of bedrooms �` (p Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity"ti . No. Compartments PKG: TREATMENT PLT. ❑ Method of Disposal i 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 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 C 'ornia." The applicast I for all ed inspecti S. Complete drawing on averse side. �� Signed itle: _ Date: FOR DEPARTMENT USE ONLY ` G Application Accepted by Date a realr Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: ❑ Stk 468-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE j INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIYNO. + EH 1426[REV.10!831 `k' Q-1 -7 Z