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- i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781, I PERMIT EXPIRES TYEAR 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.; f Job Address City Lot Size PM I I Owner's Name Address Phone Contractor Lqjrn4A�Address License No. Phone Ila, ! TYPE OF WELL/PUMP: NEW WELL D. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public Cl Other f.-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _--ApproxIDepth I I Eastern Surface Seal installed by _ I Repair Work Done LJType of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION [ No septic system permitted if public sewer is � vailable within 200 feet.) Installation will'selve: Residence= Commercial'_- Other Number of living units: Number of bedrooms f Character of soil to a depict 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 .f ❑ No. & Length of lines Total length/size I FILTER BED e ❑ Distance to nearest: Welt Foundation Property Line k I SEEPAGE PITS I I Depth Size Number IL 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 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-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 Califor The applicant mus I required inspections. Complete drawing on reverse side.&44-n= Signed X Title: Date: r FOR DEPARTMENT-USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by A ��✓ DatQr �% Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369421 ❑ 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 CK RECEIVED BY DATE PERMITNO. INFO JCASH / Q VO+.EH 13-24 IREV.)"bi �,� /D7r / //f 2 1 '90 404 EH 14-28