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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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., G Job Add(ess. .30 r?, City tri F Lot Size �Ct t talu,) PM sell Owner's Name - ss - Phone 3 II S Contractor �1 Address .!'��z f License Nj= J_3 i Phan,'Y TYPE OF WELL/PUMP: NEW WELL.-ED WELL REPLACEMENT ❑ r '" DESTRUCTION ❑ _ f PUMP INSTALLATION ❑ p�,. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES 61SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 4<'-?OTHER WELL PITS/SUMPS INTENDED USE" TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'.of Well Excavation Dia. of Well Casing C ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ;_ Type of Casingx Specifications I") Public ❑ Others Ll Delta Depth of Grout Seal . Type of Grout I ] Irrigation _.-Approxi Depth I I Eastern Surface Seal Installed by `Y �ae n r _ Repair Work Done L1 Type of Pump .H..P; �. State Work Done Well Destruction ❑ Well Diameter �. Sealing Material stop 501) Depth � x.11 Filler,Mat ire al (Below 501 yam• TYPE OF SEPTIC WORK:\.NEW INSTALLATION 11i1,,�-REPAIR/ADDITION DESTRUCTION I I (No-septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Comrriercial;-,^ Other Number of living units: — Number of bedr ours y e Character of soil to a depth of 3 feet: � �� r' Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i pistance to nearest: Well' Foundation } Property Line LEACHING LINE No. & Length of lines J Total length/size6 - FILTER BED 1 ❑ Distance to nearesWelln�"11� Foundation ?' Property Line_ SEEPAGE PITS Depths Siza � Number r SUMPS �- L] Distance to nearest: Well !T?f1, F4oundation -f 1� Property Line , DISPOSAL_PONDS ❑ I 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 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-contiacting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornpensa- tion laws of California." The applicant must--ca11'for all required'in "ctioris. Complete drawing tin reverse Signed X I Title: Date: OR DEPARTMENT USE ONLY J Application Accepted by Date Area P Pit or Grout inspection by - G Date _ Final Inspection by Date Additional Comments: ❑ Stk 466-6781CY Lodi 369-3621 © Manteca 823-7104 .❑ Tracy 835-6385 Applicant - Return all copies to: Environ#mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i i FEE INFO AMOUNTT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. �.EH 1 -241REV,1/85Y EH 144-28 ' .. I