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APPLICATION FOR PERMIT SAN JOAQUIN 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 he+eby made to the San Joaquin Local Health.District for a permit to construct and/or install the work herein described. This application is t 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. –7 Job Address � � ` City Lot Size r�• PM i I JL A Owner's Name J, NAddress , Phone j) Con tract Of 1n.Cotl= ddress � License No_ 7"Z& Phone �© TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; I PUMP INSTALLATION ❑ % _ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS It A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0-Open Bottom EI Manteca Dia. of Well Excavation Dia. of Well Casing_ II❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications (-I Public ❑ Other` Cl Delta Depth of Grout Seal Type of Grout _ r i I Irrigation _Appfox. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ; 0 Well Diameter Sealing Material (top 501 T j Depth Filler Material Melow 501 a ..TYPE OF SEPTIC WORK: NEW INSTALLATION Vir REPAIWADDITION t I DESTRUCTION I I INo septic system permitted-if-public sew6F-F-"`J !! / available within 200 feet.) W a Installation will serve: ResidenceCommercial �Iher i Number of living units: Numher of b o ms Character of soil to a depth of 3 feet: Water table depth # SEPTIC TANK ' Type/Mfg &c&e1n6=2 d Capacity_ No. Compartments .PKG. TREATMENT PLT. ❑ { Method of Disposal 1 �l Distance to nearest: Well _] Foundation Property Line LEACHING LINE No. & Length of lines —cw q0 Total length/size K z FILTER BED _ ❑ Distance to nearest: Well ! Foundation__.- � Property Line s // SEEPAGE PITS `` Depth Size Number f 'SUMPS - CI Distance to nearest: Well.,� Foundation Property Line w.DISPOSAL PONDS.-,D hereby certify that j 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 Diltrict- 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 Il.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 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 muqrbo.1 for all ire inspections. Complete drawing on reverses p Signed X Title: e Date: �U FOR DEPARTMENT USE ONLY A plication Accepted by - Date' r Area ! or Grout Inspection by ate ' Final Inspection by � Date/ Additional Comments: !i ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 n FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY 4 DATE PERMIT NO. +.EH 13-24/REV.1/85) 1 EH 14-29 r