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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (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. Jab Address 00 City Lot Size 5� PM �s Owner's Name 1 f 2 2�111 Zx Address 3 a 3 N - f Phone 34b , 1 2 � Contractor's Name ¢'� • J License No. 6 7.21 Phone 3&F �J TYPE.OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION'C3` ' SYSTEM REPAIR-❑ �- "OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEWAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial;F_; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout + ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done IDType of Pump H.P. ` State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Belo 50'1' TYPE OF SEPTIC WORK: NEW INSOLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of bedrooms. it Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg. �'- � Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation `Property Line LEACHING LINE 2--No. & Length of lines CTotal length/size 0 FILTER BED EIt,Distance to nearest: Well� -Foundation .O 1 Property Line__L_ SEEPAGE PITS Depth cS Size S Number° ` SUMPS ❑ Distance to nearest: WellJ Sd Foundation-PLO t' Property Line )60 DISPOSAL PONDS 0 1 1 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 n 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." The applicant must call fo all r uired 'inspections. Complete drawing on reverse � side. Signed X e�.• Title: W e-4 Date: /0 FOR DE RTMENT USE ONLY i Application Accepted by Date 6 Area / r Grout Inspection by ' Date / Final-Inspection'b ate Additional Comments: "M — ❑ Stk 466-6781 ❑ 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED {CASH RECEIVED BY DATE PERMIT'`NO. + EH 13-24(REV.10/83) o , a EH 1426