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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 pePERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'` � PG�` +r� (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. Job Address 1DiY em City L e Yot Size PM Owner's Namex_—M✓1 G Aid Jr� Ca.-- T Addressl Phone + i Contractor d c Address ¢r" License No.322) Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r 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 l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public f_i Other ❑ Delta Depth of Grout Seal Type of Grout (r�� I I Irrigation --Approx. Depth l I Eastern Surface Seat Installed by 4 _ v Repair Work Done 1RQ Type of Pump T-Z�,___. H.P. 5 _. State Work Done �z Well Destruction ❑ Well Diameter Sealing Material Itop 50') { /s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other z Number of living units: Number of bedrooms r Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.`Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS Cl 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 i 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(tiring 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 com sa- tion laws of California." The applican i call for all requir specti s. Co to drawing on r se side. Signed X Title: -- �s -Date: _ PARTMENT USE ONLY"' Application Accepted by Date Area Pit or Grout Inspection by Date 1 Final Inspection by �'' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-361'1 ❑ 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 95241 INF 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT'NO. +.EH1 -21IpEY.tiHsl �S t-��7--� �f EH 114-2t7 UUU ! r ' ' u