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APPLICATION FOR PERMIT {- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,--1 ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jl (Complete in Triplicate) II 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 Ordfpance No.549 for sewage-or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dis#rict. a�, 7Jab Address 0 S- City Lot Size PM Owner's Name A Address - oafPhone Contractor's Name ii 'cense No. p Phone - r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ ` DESTRUCTION ❑ T� PUMP INSTALLATION El SYSTEM REPAIR L1 OTHER El 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 —❑ 'Industrial ❑ Open Bottom ❑ Manteca ",''Dia. of Well Excavation Dia. of Well Casing pa Domestic/Private 13Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ,. Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 + TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIR/ADDITION ❑' DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) / Installation will serve: Residence v Commercial— Other 3 Number of living units:T Number of bedrooms r Character of soil to a depth:of 3 feet: Water table depth SEPTIC TANK C� s:Type/Mfg Capacity �a No. Compartments PKG. TREATMENT PLT. ❑ it -- Method of Disposal j Distance to nearest: t Well Foundation Property Line —5— LEACHING —LEACHING LINE_ r ? —No.. & Length-,of-lines G dotal length/size d FILTER BED ❑ 'Distance to.•nearest: Well 4 Foundation/G Property Line_s I� SEEPAGE PITS ❑ iiI Depth Size Number �y 5 r SUMPS El, to nearest: Well Foundation Property Line l DISPOSAL PONQS1 ❑ 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 Calffornias' The applicant must call or ail re 'red in pectione Complete dra+niing•on reverse side. 1 Signed w : Title: C .+t�� — Date: .FOR DEPARTMENT USE ONLY , Application Acceptgd byX.�. Date �� Area L i' + Pit or Grout Inspection by Date�.� Final Inspection by Date I it Additional Comments: ❑ Stk 466-6781 ,-❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 3_ _ r EH 13.2A(REV.10!83) 331 ��"r / !Q I �� EH 1426