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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT �v 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 U 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.649dor sewage or No. 1862 for walUpurnP and the Rules and Regulations o1 the San Joaquin Local Health District. - q _ Job Ad 'dress /II I '"!�76 dI f�J J1.1 (r) City` ' Lot Size ) 4' PM Owner's Name• E�C T ItJ4N h s-'• R Adress (!!`� V'°1" - hone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 Die. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifiicffiions ❑ Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work e _ Well Destruction kl' Well Diameter Sealing Material (top 50') rniA IllL' Depth Filler Materia! (Below 601 TYPE OF SEPTIC WORK: NEIN INSTALLATION I1 REPAIR/ADDITION LI DESTRUCTION I I (No sap ystem permitted if public sewer is 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 Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 agents 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 workmen'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 shell employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete dfawing on reverse side. 1 Signed K FOR DEPARTMENT USE ONLY Application Accepted by IJ'Cr �\.X Date � Area ?f Pit or Grout Inspection by Date Final in ion by ^�� Date , Additional Comments: I , ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 U ❑ Tracy 835-6385 \ nt• Return all copes to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952(11 FEECK Jam, INFO AMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT NO �I