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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 „ r� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) xt: J 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 Ruled and Regulations of the San Joaquin Local Health District: Job Address iAs�V f f ' City O C� Lot Size PM Owner's Name 1' 4�N �^ Address �' GL Phone Q Contractor's Name (�ELL� U,i P License No. O Phone 6 �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑, PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 01 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE s 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. bf Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal TypeofGrout ❑ Irrigation ---Approx. De h ❑ Eastern �1 urface Seal Installed by t Repair Work Done ❑ Type of Pump u� H.P. ApZ State Work Done ZN TMtL. AIEW P►lIJA Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth J1qi Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system peirmitted if public sewer is t available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of iiving units: Number of bedrooms Character of soil to Ef`depth of 3 feet: Water table depth SEPjIC TAMC-.. . :Type/Mfg Capacity No. Compartments PKG.'TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 3 ❑ Depth Size Number F SUMPS """ ❑ Distance to nearest: 1 Well Foundation Property Line DISPOSAL PONDS ❑ �, a 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 ' 'rales and-regulations-of the San'Joequirl Local Health-District.- •�--- w �-- ---�_- - - �-- .. ---.--� 4 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 n in such mariner as to become subject to workman's compensation.livA o&'Cal'ifornia."Contractor's hiring or sub-contracting signature certifies the f Ilo ingi"I-certify at in the rformance of the work for which this permit is issued,I shall employ persons sdbject to workman's compensa- tion laws of I' nia." s The applicant st call for all re d i s ions. C plate drawing onjoverse side.— # &Y Signed Title: Date: v DEPARTMENT USE ONLY Application Accepted by v " pate �r��" 'l Area PR or Grout Inspection by Date F nal Inspection by Date Additional Comments: 9Stk 466-6781 1, ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUnE AMOUNT REMITTED CASHCKRECEIVED BY DATE a € PQERRMIT"NpO. + EH 13.24(REV.10/63! 14b (5V EH 1426