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yr APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. r Job Address �_,2, 3 6 City Lot Size PM Owner's Name L dress Phone Y 11 Contractor Address License No. Phone 7 TYPE OF WEL IPU P: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 C] Manteca Dia. of Well Excavation Dia. f Well Casing 11 Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications — M Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ •I 1 Irrigation _Approx. Depth I k Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. . State Work Done Well Destruction ❑ Well Diameter ealing Material Itop 50'1 Depth Filler Material IBelow 501 w TYPE OF SEPTIC WORK: NEW INSTALLATION i' REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.I 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 Capacity No. Compartments PKG, TREATMENT PLT. ❑ y- Method o t sal Distance to nearest: Well Foundation t�_r' _...._._ Property Line LEACHING LINE ❑ No. & Length of lines `-- ` T tal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - SEEPAGE PITS l I Depth Size Number r SUMPS y Ll Distance to nearest:" Wel Foundation�_ Property Line DISPOSAL PONDS 11 I hereby certify that I have prepared this application and that the work will he 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 taws 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant r1t quir i spe tions. Comp) drawing on reverse side. Signed X - Title: Dater �91X 7/0----' FOR DEPARTMENT USE ONLY `] Application Accepted by Da f— Area it or Grout Inspection by to �� f v Fnal Inspection by ��/f Date 6 k Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I K H RECEIVED BY DATE PERM jWf.♦.EH 13-241REV.1/x51 INFO ^4 /d� EH u-215 -