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APPLICATION FOR PERMIT C IT { j SAN JOAQUIN LOCAL HEALTH DISTRICT M l 1601 E. HAZELTON AVE., STOCKTON CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDa'ujitiiOCA (Complete in Triplicate) N,XTH-1 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 No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address City Lot Size PM Owner's Name ddress r Phone �^ t Contractor's Name ' � � Cense No.A� 3 Phon on TYPE OF WELL/PUMP: NEW WELL ❑ `ti WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ T DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. } PROP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS T' } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' J O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation F i Dia. of Well Casing lvi Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - r Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i Type of Grout - ❑ Irrigation --Approx. Dep h ❑ Eastern Surface Seal Installed by Repair Work Done E?" Type of Pump / H.P. 3 State Work Dane' Well Destruction ❑ Well Diameter Sealing Material (top 50') �, = Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑' REPAtR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s k� . ``� *$ h e available within 200 feet.) w� Installation will serve: Residence. V Commercial "Other Number of living•units: = ,``? _Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/MfgCapacity Na. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number•• SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ -- 4 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not l employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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- I tion laws of Calif The applicant u ca for all re ed inspections. Complete drawing o e side. i g r-1/ Si ned • Date: r FOR DEPARTMENT USE ONLY ' Application Accepted by Date `-41F Area t � Pit or Grout Inspection by ---�Fina!_inspection_bDate 1/ Additional Comments: - - r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 FEE AMOUNT DUE AMOUNT REMITTED CK* ' RECEIVED BY DATE PERMIT'NO. INFO r j CASH " ,• + EH 13-24 lREv.10/83) S _ jam] F7-1b „� FtY- EH 1428 - rte'