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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 465-6781' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I x (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 r 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.. O y` City_�� 3 PM I. Job Address -,-t Size Owner's Name !1,� � T .� Address r Phone C� 1111116A Contractor's Name AeoO F� License No. Phone TYPE OF WELL/PUMP: NEW WELL II WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ;jb^QWe.-AVi9YSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ".k..... INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' C1 Public r ❑ 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 (top 501 A"24AI? V s7. AA AIBV e V Depth !' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other k -Number of living units; Number of bedrooms _Ch racter of-soil'to-a-ilepth,of 3 feet: Water table depth y%,�SEPTIC�TANK`-� ❑.Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑" Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O-No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I E _ SEEPAGE PITS ❑' Depth Size, Number SUMPS ❑' Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that th'.work'wl l be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local-Health District. 3 A. 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 I employ any person in such manner as t6 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 fcoAll re t inspections. Complete drawing on riLvers 90bide. 3 i Title:Signed Date: , M7MENT.USE ONLYApplication Accepted by S Date �r Area is - Date Pit or Grout Inspection by to Finaf.lnspection by Additional Comments: ❑ 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 X FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE f ERMIT"NO. INFO EH 1324(REV.10/83) �r ' EH 14-28