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APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT � UJ 1601 E. HAZEL T ON AVE., STOCKTON, CA a'= xO Telephone (209) 466-6781 "�' c� r;, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <a (Complete in Triplicate) y Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the work described, f5i�-epplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1852 for well/pump and the Rules f tions o�he San Joaquin Local Health District. t Job Addressy �� y_ City Lot Size PM 11 Owner's Name Z �G f�✓�--� Address 3 Phone F Contractor Address IM /& ti (Z 9-5.3P License No.6 �3�."__Y6 Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER"LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r E ❑ Industrial ❑ Open Bottom . ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications i`I Public ❑ 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.�- u�— _ H.P. �j State Work pone [ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler_Matarial (B_elow 50')•' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTiO.N LtNo septic system permitted if public sewer is ,;,0- 'available within 200 feet.) (�� Installation will serve: Residence— Commercial_ Other" , Number of living units: Number of bedrooms V) Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK t, p Type/Mfg `e 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 I I Depth I Size Number SUMPS ❑ 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 accordance with San"Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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-contracting 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 compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ," l Signed X Title: d� V-1/91 —IF-91 Date: R DEPARTMENT USE ONLY p Application Accepted by ' Date ,._ Area Pit or Grout Inspection by Date Final Inspection Date6_ 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 FEE AMOUNT DUE AMOUNT REMITTED �K RECEFVED BY DATE PERMIT"ND. INFO CASH + Eli1424fREV.tix51 EH 14-2a /