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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' a (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 City Lot Size �CJ PM _ . Owner's Naame Address " _ 1 Phone Contractor" Address G(.License No. O TYPE OF WELL/PUMP: Phone NEW WELL jQ WELL REPLACEMENT ❑ DESTRUCTION ❑ �.. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -AM " SEWER LINES DISPOSAL FLD./,3'0 PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL- .- �PITS/SUMPS INTENDED USE -TYPE OF WELL PROBLEMAREA CONSTRUCTION_ SPECIFICATIONS ❑ Industrial ❑ Oen Bottom. Open � Manteca Dia. of Well Excavation Dia. of Well Casing )(Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Olrrigation ---q r Type Grout ---Approx. Depth ❑ Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Filler Material (Below 501 " TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/AUDITION ❑ DESTRUCTION ❑FIND septic system permiLU tted if public sewer is r Installation will serve: Residence, Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments ffffff ) PKG. TREATMENT PLT. IDr, —J Method of Disposal a Distance to nearest: Well Foundation Property Line v J, �.. LEACHING LINE ❑ No. & Length,of lines - Total length/size FILTER BED ❑ Distance toy naa"rest: Well Foundation' Property Line SEEPAGE PITS ❑ Depth • `" r Size • ) r Number 'T SUMPS $ ❑ Distance tajn_earest:. We11 _ 'Foundation_ pro DISPOSAL PONDS ❑ ¢: ,- Pe►ty Line � r ` i hereby certify that i have prepared this application and that the workwillbe 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, f shall not k 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-rformance of the work for.which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." s The applicant friust call for all requ inspections. Complete drawing on reve side. t g k Si ned Title: Date: 1Q FOR DEPAR MENT USE ON ' y Application Accepted by Date �l (� �7 r Area �CJ Ph or Grout Inspection by. atef Final Inspection by Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-36211 0 Manteca 823-7104 ' '❑ Tracy 835-6M i Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 1 INFO AMOUNT DUE =REMITTEDRECEIVED BY DATE PERMIT'NO. +EH13-24(REV.1/95)EH 1-- I � r�