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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA 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 vLocal Health-District. Job Address �7 d L C.c/ __ - City Lot Size PM ,' Owner's Na Address5�al to'G / Phone C! DSI Contractor AddressZZ2 -yl�, License No.'7 5790 Phone23g. •—Y � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K s .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 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 Z Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other - ❑ Delta Depth of Grout Sea] Type of Grout W ❑ Irrigation _Approx. Depth Eastern Surface Seal Installed by Repair Work Done .@T Type of Pump H.P. State Work Done. Well Destruction ❑ Well Diameter Sealing Material [top 501) Depth Finer Material [Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ]No septic system permitted if public sewer is Ys 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 �o SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line l LEACHING LINE ❑ No. & Length of lines ! a• "` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I � f 'SEEPAGE PITS ❑ Depth Size Number }SUMPS ❑ Distance to nearest: Well Foundation Property Line F ` 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 rules and regulations of the San Joaquin Local Health District. i_ 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 shell employ persons subject to workman's compensa- tion laws of California." The applicant must call for II required inspections. Complete drawing averse side. 1 / S f i Signed X �Lh Title +f R Date: FOR DEPART M NT USE ONLY i •Application Accepted by Date Area Pit or Grout Inspection byDate Final Inspection by Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantbca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO CASR EH 13-24+ EH W261REV.i/85) 3 pb-1 Ali-