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R r t APPLICATION FOR PERMIT- SAN ERMITSAN JOAQUIN LOCAL HEALTH DISTRICT w- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 (Complete in Triplicate) E APpkation 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 nada in comphance.with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin , Lccat Heakh District. Job Address City Lot Size Owner's Name Address �.CQ -- Phone ✓ 'Conteactor Address License No. Phone ` „ ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 91 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ r " DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL fLD. PROP: LINE FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/,SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom , ❑ Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public Ll Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I ! Eastern Surface Seal Installed by - C' I Repair Work Done ❑ Type of Pump . H.P. State Work Done_ Well Destruction ❑ Welt Diameter Sealing Material [top 501 r� Depth Filler Material [Below 501 +� TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION l I DESTRUCTION t I (No septic system permitted it public sewer is r available within 200 feet.) (ice Installation will serve: Residence commercial T� Other 'Number of living units: Number of bedrooms✓ w 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. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS Depth Size 2 l� ,� NWber J SUMPS Distance to nearest: Well ACD/2 Foundations Property Line DISPOSAL PONDS ❑ , <` hereby certify that I have prepared this application arld 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. x Horne 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 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 applican 71I r equire ctions. Comp) to wing.on rse side. w / Signed Title: Date: v F DEPARTMENT USE ONLY 1 Application Accepted by C Date tom'`�� Area ` r Grout Ins ion b Date a Final Inspection by Datt� ' oval Comrtfents: t Stk b66-6781 ❑ Lodi 369-3621 ❑ Manteca" 823-7144 ❑ Tracy 835-6385" Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA$5201 FEEAMOUNT DUE AMOUNT REMITTGASH ED CK INFO RECEIVED BY DATE PERMIT"NO. 10 + EH 13-24IREV.I/x5) jp �/ I — ID LIA L —,3151K EH 14-je - fff r�+� ! I