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APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _. PERMIT EXPIRES 7 YEAR FROM DATE ISSUED -11L41- (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 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. - S , I ' Job Address r 4 City�I de1�1 of Size "� PM Owner's Name Address � ��i Phone W1,41 �d Contractor d Address SA IK ' License No. Phone TYPE OF WELL/PUMP: NEW.WELL-.❑_ .. WELL REPLACEMENT D m DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �MERWELL_ A OTHER'❑ DISTANCE TO NEAREST: SEPTIC TANK SEW LINES D . PROP. LINE FOUNDATION AGRICUL URE WELL PITS/SUMPS _ INTENDED,USE TYPE OF WELL PROBLEM AREA NS TION SPECIFICATIONS ❑ Industrial } ❑ Open Bottom ❑ Manteca �f Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type oi-Casing Specifications t ❑ Public ❑ Other eta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. De ❑ Eastern Surface Seal Installed by j Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial, Other a o Number of iving units: Number of bedrooms _T Character of`soil to a depth of 3 feet: Water table depth �! SEPTIC TANK* ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal `. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines N Total length/size FILTER HED F] Distance to nearest: Well Foundation Property Line SEEPAGE PITS LlDepth Size Number SUMPS ❑ Distance to nearest: .{. Well Foundation Property Line �y DISPOSAL PONDS L1 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, ander• 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 shali employ persons subject to workman's compensa- tion laws of California." - 'cant m t c Il far all equ' inspections. Complete drawing on reverse side. Signed Z Title: Date: i _ . FOR DEPARTMENT USE ONLY p _ p ication Accepted by Date a Area Pit or Grout Inspection by Date Final Inspection b Data Additional Comments- YKAr ❑ Stk 466-6781 7-1Lodi369-3621 ❑ Manteca 823-7144 ❑ Tracy 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 !G + EH 13.24 IREV.i/B 5) �- '7 GS '87 EH W28 -