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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 RF—C-EWE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2 9 f,989 (Complete in Triplicate) gISAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thege.' v8flk�lse�iFi c� l I cation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t€�VOMONtAEN;UWHEALOHtDIVI 5181o0quin Local Health District. Job Address O City Lot Size 4 rM Owner's Name I� Address Phone ' J Contractor L Address V Zicense No. Phone r TYPE OF WELL/PUMP: NEW WELL ��ZWELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3&, wtaf 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 ElManteca Dia. of Well Excavation ia. of Well Casing r ❑ Domestic/Pri if4 Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public f ! Other Cl Delta Depth of Grout Seal Type of Grout _. . I I Irrigation _lf pprox. Depth ( I Eastern Surface Seal Installed by - Repair Work Done ❑ Type'�of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1_1 DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms F Character of soil to a depth of 3 feet: Water table depth i _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. ❑ 11 Method of Disposal Distance to nearest: Well Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I �I SEEPAGE PITS I'1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. 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''hat in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required ins pe tions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USEO LY f Application Accepted by AW. Date Area F Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: M 6 7�r ❑ Stk 466-6781 ❑ Lodi -3621 Q Monte 823-7104 ❑ Tracy VOW.'; 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. �.q INFO CASH ♦T EH 13-24(HEV.1/H 5) EH 14-26 II a