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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ® + Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED S s,i f�lr1� (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the wofkr��rr3 ascribed. 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. I , Job Addres S City Lot Size PM �E C O � Owner's Name. - Address ` ` P . - IF Contractor r! a l �( —Address icehse No. &7' Phone95150—.287 TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION EI PUM INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ t 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 ED Industrial E] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CDomestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications 1-1 Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout I i Irrigation --Approx. Depth I I Eastern /$urface Seal Installed 6y Repair Work Dane ❑ Type of Pump H.P. ork Done � �-- State W Well Destruction ❑ Well Diameter Sealing Material (top 50 l Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence_ Commercial_ Other Number of living units: i Number of bedrooms Character of soil to a depth ofl3 feet: Water table depth' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ I� Method of Disposal Diastance to nearest: Well Foundation Property Line LEACHING LINE ❑ N4& Length of lines Total length/size FILTER BED ❑ distance to nearest: Well Foundation -Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 t rules and regulations of the San ,`oaquin Local Health District. Homeowner 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 tli'at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The applican t II for alt re'I ired inspections. Complete drawing on reverse side. Sign Title: Date:`©` " FO PARI E SE ONLY Application Accepted by T 're Pit or Grout Inspection by s Date Final Inspection by/ Date/ Additional Comments: ❑ 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 FEE �!I CK INFO MOUNT�DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 1 REV.1/95) r , EH 14-28 ..