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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 Saniboaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j Jab Address �Z�I� City Lot Size PM Owner's Nam a5m Address Phone A ry ill { Contractor isa&Address License No. Pho_ TYPE OF WELL/PUMP: �I�, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 r I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .4. g Specifications f`1 Public F1'Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation 1I'._Approx. Depth I i Eastern Surface Seal Installed by p Repair Work Done ❑ Type of Pump H.P. State Work Dane_ �1 Well Destruction ❑ Well Diameter Sealing Material /top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I:] HEPAIM ADDI I IuN^ DESTRUCTION I ] INo septic system permitted it public sewer is II� available within 200 feet.) Installation will serve: Residpence Commercial_ Other Number of living units:._J1! Number of bedrooms Character of soil to a depthl� f 3 feet: _ .. Water table depth SEPTIC TANK 0 Type/Mfg Ca acit Y No. Compartments PKG. TREATMENT PLT. Eloil. p Method of Disposal istance to nearest: Well Foundation Property Line I LEACHING LINE �No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well FoundationProperty Line I� . il. SEEPAGE PITS Depth !:I El 0 Number f SUMPS l Distance to.nearest: Well 4A"4V__tFaundation�_ PropePty Line DISPOSAL PONDS ❑ J 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 agents 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 mariner 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: ,Ife it d ins ction Co to drawing on reverse side. Signed :! Tit] Date: ^" FO EP USE b USE ONLY rr k1 Application Accepted by _ Date �� Z) Area L ! Pit or Grout inspection by !I�I Date Final Inspection by Date(/ Additional Comments: ❑ Stk 466-6781 -. CJ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to`` Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Bax 2009, Stk., CA 95201 I i FEE AMOUNT DUE AMOUNT REMITTED CK INF ;r CASH RECEIVED BY DATE PERMIT'NO. ; EH 14-2g IREV.1/85, .i i+t 51 L rl�� f/r0 AY67 J �II [ _ A�1`�� t �I