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f APPLICATION FOR PERMIT PAYMENT `tl SAN JOAQUIN LOCALHEALTH DISTRICT REEWE® k 1601 E. HAZELTON AVE., STOCKTON, CA MAY 2 9 198 Telephone (209) 466-6781 SAN JOAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUE UBLIC HEALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL HEALTH DIVISION 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 Otdinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. AW L Job Address City Lot Size !� CLP PM Phone Owner's Name R" Address Address f License No. Phone � Contractor�( , TYPE OF WELL/PUMP: i�' NEW WELL Q�j9 WELL REPLACEMENT ❑ DESTRUCTION ❑ t� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑�pen Bottom ❑ Manteca Dia. of Well Excavation Ia. of Wel! Casing ❑ OomesticlPrlvat d� CV Gravel Pack ❑ Tracy Type of Casing Specifications tl Public ,� F1 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation I �L:Approx. Depth l 1 Eastern Surface.Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �. Well Destruction ❑ Weill Diameter Sealing Material (top,501 Depth Filler Material (Below 501 2 TYPE OF SEPTIC WORK: NEW INSTALLATION t-1 REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is I" I� available within 200 feet.) Installation will serve: Residence— Commercial_ Other ^ Number of living units: A Number of bedrooms' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ q1. Method of Disposal ;IDistance to nearest: Well Foundation Property.Line `A 4. Total len th/size LEACHING LINE ❑ No. & Length of lines g F- FILTER BED ❑ Distance to nearest: Well Foundation Property Line I ni SEEPAGE PITS l I Depth Size Number SUS MP5 Cl '`Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IN kA 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 4' r rules and regulations of the San Joaquin Local Health District. t� fff Home owner or licensed agent's signature certifies the following: "t 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. Contractors 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." I' The applicant must call for all required inspections. Complete drawing on reverse side, E d t Signed X Title: Date: l FOR DEPARTMENT USE ONLY f� j "" rea Application Accepted by Date A e Pit or Grout Inspection Date— Final Inspection Date ". .i Additional Comments: lo? I . ❑ Stk 466-6781 [1 Lodi 369-3621 ❑ Manteca 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 is FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. p_ INFO R t r.EH 13-241REV.1/n5) - .. £H 14-28 III _