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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2 9 1489 (Complete in Triplicate) pp SAN.1QAC UIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t� 19%0W eiHS Ii�cSFRIIIl caIion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t lY NMEAI;jWHWJHt9Ivrm04gnin Local Health District. Job AddressI ! �O �`J --=�'` l�C�(�.-_�� City Lot Size Jexl- Owner's Name r 06Address - _� rPhone Contractor 4e"fireJ&C Address 7DO icense No. Phone TYPE OF WELL/PUMP: NEW WELL V _ WELL REPLACEMENT DESTRUCTION Ll PUMP INSTALLATION ❑ �� Z� SYSTEM REPAIR Ll OTHER ❑ < . WIT 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 f 1 Industrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ ( I Domestic/Pri (!�( Gravel Pack El Tracy Type of Casing Specifications ('1 Public (7 Other F1 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 H.P. _ State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 501 _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_-_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ —Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C7 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 Size _ Number _ SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 D(ktrict. 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 in tions. complete drawing on reverse side. Signed X_ _ Title: Date: FOR DEPARTMENT USE O LY Application Accepted by Date ,� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: et ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Mantec 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 f FEE AMOUNT DUE AMOUNT REMITTED I INFO CASH RECEIVED BY DATE PERMIT N0. EH 1320(REV.f i H 5) EH 14 28 O o �! ��, �—