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APPLICATION FOR PERMIT C1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 c(op IC PERMIT EXPIRES 7'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 District. C U Alm71 ! �C ` Job Address , City �C / Lot Size r� PM T �/ f Owner's Name �� Address Phone Contractor �Aess License No �_ ��/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCMON = PUMP INSTALLATION a; SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PtTS'SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing Specncations i Public l-i Other �l Delta Depth of Grout Seal Type of I f G � I I Irrigation ___.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done IJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') —_ TY/PE OFStP1ICP'ORK: NEW A INSTATiON EPAIR/A ION l I DEST CTION I I (No septic system permitted if public sewer is & /Y#I( 9; � - : s i a available within 200 f_et.l Installation will sery Residence - Co mercial _ Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth `c1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 a�cordanca with San Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health Diltrict. `.. Home owner or licensed agent's signature certifies the following: "1 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 that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m�t call for all required inspections. C mplleete drawing on reverse side. Signed X_ J r ��L TitPa�! s t� -�.�� Date: . / i R DEPARTMENT USE ONLY �j Application Accepted by0&6* Date Area 1I Pit or Grout Inspection by bate Final Inspection by Date Additional Comments: Q, c2 i ❑ Stk 466-6781 ❑ Lodi 369 M nteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton'Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE ?ERN117'No. INFO {� �l c�, 7 may) . EH 13-24IREY.i/mtj 7(� • 4 0 t CjO Sqk �1� ��,�Y-1 G? l "1Li EH 1426