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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELiON AVE., STOCKTON, CA RECEIVEDTelephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR " 9 1989 (Complete in Triplicate) SAN JOAQUIN COUNTY sl:avlCES 1W ication is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ins I rtl �{L� �"T��.p��mp�' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump a egu%V of the San Joaquin Local Health District. /J�' r, ("A . Job Address ==,ddress z City 4�Lo/t Size PM Owner's Nam Phone` :V '{ Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION O __SYSTEM REPAIR ❑ _ OTHER ❑ ^j DISTANCE TO NEAREST: SEPTIC TANK. dK 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public n Other C 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 Itop 501 Depth Finer Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L1 Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Jan FILTER BED ❑ Distance tonearest: Weil Foundation Property Line SEEPAGEPITSIIDepth Size NumberSUMPS LlDistance 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, rules and regulations of the San Joaquin Local Health DRarict. 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 requir inspections. Complete drawing on reverse side. Signed X� Title:61k — Date: / TMENT USE ONLY Application Accepted by Date d Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. l ♦.EH 13-2 IREV.1/851 EH 11-2fl