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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone {209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED r x 4Cornplete in Triplicate), F 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 2 for well/pump and the Rules and Regulations of the San Joaquin ; Local Health District. ;" „ a:" /' _ _ ,moi .City Lot Siz �� PM Job Address Owner's Name - Address ,gyp G. rsj if Contractor f � Address t ""` �"p�License No.�t'� �x phon26—�� < TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR_❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES x DISPOSAL FLD. _ PROP. LINE w 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 ❑ 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 atop 501 `" Depth % Filler Material Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIOX DESTRUCTION ❑ (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. ❑ Meihod of Disposal I I Distance to nearest: Well Foundation �—Property Line LEACHING LINE J0—No. & Length of lines Total length/size- FILTER BED ❑ Distance to asst: Well`7` Foundation f5 l Property Line': fes' f SEEPAGE PITS -a'Depth Size N !j Numbei SUMPS ❑ Distance to nearest: Well Foundation .._) Property tine DISPOSAL PONDS ❑ C 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 T 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 California." _ J The applic nt must all for arequir ins tions. Complete drawing on reverse side. Signed Xi� �i� u-•� Title: ��cJ= r Date. OR 4EPARTMENT USE ONLY Application Acceptby Date I.O^ `L^%Z Pit or Grout Inspection by Date Final Inspection by\ Date t \ � " Additional Comments: ' y! '� 4 ` /V 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 CA H RECEIVED 8Y DATE PERMIT'N0. INFO y f i .+ EH 13-241REV.i/86) EH 14-28