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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 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 0 DisSrict: r. Job Add s FCf M City Lot Size (L Owners Name ✓ Address �7Q 1 Phone ZfContractor ddress License No/ Phone V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FIA. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout r ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dore Cl Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material (Below 501 TYPE TOF SEPi1C WORK: NEW INSTALLATION JEPAIR/ADDITIOONN❑ U9rION ❑ (No septic system permitted if public sewer is ' ' �r,� 6L'l•, available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: ' 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. ❑ Method of.0_mposal Distance to nearest: Well 140 Foundation,, /l Property Line 1�" 'b� EACHING LINE ❑ No. & Length of lines "' Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line / r EEPAGE IT ❑ Depth Size d�f(„7 _Number SUMPS ❑ 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 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 hiring or subcontracting 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 applican ust II for allr inspections. CompI to drawing on/r e�ry'se side. Signed X-� 47/ - ��L Title: b � Date: FOR DEPARTMENT USE ONLY Application Accepted by ---------� Date ( Area / �j Pit or Grout Inspection by �zr Da e{)t ,Fiinal�Inns/peccti n by 92� y�1�/ — Data 1 r 1�3-i �7Q Additional Comments: C46f 1&V� 'h Toy[A • (�_"�L�r^i'is'r� �r"s ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED ,SN RECEIVED BY DATE PERMIT-NO. �24 EH 14261R1Y.1/65) `�3