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i} APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C! O u V )Complete in Triplicate) � Application is.hereby made to the San Joaquin Local Health District for a permit to construct and/orinstall the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welll,pump and the Rules and Regulations of the San Joaquin g Local Health District. (3AV'74 i ;_Z �=„?i / cit Lot Size & JC/� PM Job Address _ Y `! Owner's Ne C 0 R Address Phone r I Contractor GLC �� 9 License No. {j Phone_ � Address _, c ,:_ r TYPE OF WELLlPUMP: . •" NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION_❑ E' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' . DISTANCE TO NEAREST: SEPTI -,TANK °°' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION J AGRICULTURE WELL OTHER WELL ! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Operi Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing GN El Domestic/Private C1Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other C1 Delta Depth of Grout Seal . Type of Grout I I Irrigation —.Approx. Depth I I Eastern, Surface Seal Installed by - 1 Repair Work Done ❑-- -Type of.Pump H.P. State Work Done Well;Destruction Cl Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 I TYPE OF SEPTIC'WORK: NEW INSTALLATION l l REPAIR/ADDITION DESTRUCTION €1 (No septic system permitted if public sewer is available within 200 feet.) F Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: A �%` Water table depth ' SEPTIC TANK , ❑ Type/Mfg a capacity No. Compartments PKG.'TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WeII67 Foundation . �� Property Line �i --- — --- _ " LEACHING LINE ❑ No. & Length of lines j7 X '�` Total length/,size SQ FT FILTER BED, Distance to,nearest:_ Well_ Foundation'1 h Fes' Property Line ZAJ >� it 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 appli-cation anaiat the work will be done in accordance.vi ith.San.,Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heglth3istrict. , ; Home owner or licensed agent's signature certifies theriollowing: "I certify that in the performance of the work for which this permit is issued I sfialhnot employ any person in such manner as to become subject to workman's compensate n'taws of California."Contractors hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for which this p rmit is issued,I shallemploypersons subject to workman'si bmpensa- tion laws of California." w The applicant must call far a!I required inspection's. Compiete drawing on reverse side, Signed X rTitle: 4244-Q— Dater 11" $� Fak DEPARTMENT USE ONLY AL Application Accepted by f, _ Date Area l Pit or Grout inspection byDate Final Inspection by ✓ Dates ... Additional Comments: ❑ 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 y `' is t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +1+ 'INFO CASH 41 1 + EH 13.24[REV.i i R 5) 111 EH t4-29 ,l