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V..I APPLICATION FOR PERMIT ...r 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 Regulati s e San Joaquin Local Health District. U �A/1 ' j/. 1 ' )/y /� �� L C ^,i /� ^ 10 Job Address �� 1 Y l O wL.et ! �� City-� r� Lot Size V� / PM /V�l1 •`J Owner's Name CLQ Address SA M r��/i,� _ Phone L �✓ � }/�� Contractor's Name CSA. 1 K` 'v�L nse No. 3 7/ r! D Phone �` TYPE OF WELL/PUMP: NEW WELL ET WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC NS 3 V ❑ Industrial ❑ Ope ttom ❑ Manteca Dia. of Well Exc ati Dia. of Well Casing '❑ Domes! /Private ravel Pack ❑ Tr Type of Casing Specifications� �� ❑ P c ❑ Other Delta Depth of Grout Seal Type of Grout 'v rrigaiion ---Approx. Depth ❑ Eastern Surface Seal Installed by J Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 ,I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial— Other r 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 G PKG. TREATMENT PLT. ❑ Method of Disposal __ C Distance to nearest: Well Foundation Property Line ;- S i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 ag ature 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 anner a to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: 'I c that i e ormanc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Car mi / The applican I for I r red i ki o plate drawing on ruse sides Signed Title: Y0 C /1/(- Date2Wq,,.- gb: i FOR DEPART NT USE ONLY Q�f ,�t'1 Application Accepted by Date r� "' �t� '� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: •- (r1' ❑ Stk 4664'/61 ❑ Lodi 365-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK INFO AMOUNT DUE FEE AMOUNT REMITTED CASH RECEIVED BY DATE F RMITNO. ai�3z4(REV.10/83) --IC�FII�