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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA D 1►� Telephone (208) 466-6781 y PERMIT EXPIRES TYEAR FROM DATE ISSUED NOV 5 1988w: (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 quin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules p MIT 1 SERVICESES Local Health District. I Q Cit Lot Size PM Job Address f ddress i Phone Owner's Name I Address ice se No. Phon Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ i TYPE OF WELL-/PUMP: NEW WELL 11 OTHER ❑ ! PUMP INSTALLATION X_ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing )(Industrial .❑ Open Bottom ❑.Manteca Dia. of Well Excavation Type of Casing Specifications Domestic/Private ❑ Gravel Pack LI Tracy Type of Grout — {-I Public F1 Other n Delta Depth of Grout Seal I"I Irrigation _—L-Approx. Depth i I Eastern Surface Seal Installed by , # Repair Work Done ❑ Type of Pump. H.P. State Work Well Destruction ❑ WelI Diameter Sealing Material'itop 501 {� Depth Filler Material (Below 501 _ "1f I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I' DESTRUCTION I 1 INo septic system permitted if public sewer is O yi available within 200 feet.] Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms ]1S_ Character of soil to a depth of 3.feet: Water table depth m SEPTIC TANK ❑ Type/Mfg Capacity -No. Compartments PKG. TREATMENT PLT. * Method of Disposal ❑ Distance to nearest: Well Foundation Property Line F LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED El !!Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Siie Number SUMPS ❑ ''Distance to nearest:.., Wel] Foundation Property Line . l � : DISPOSAL. PONDS I hereby certify that I have piepared 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 Diatrict. ,. k Home owner or licensed agent's signature certifies the following: "(`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." Contractors hiring of sub-contracting signature- certifies the following: "I certify that in the-performance of the work-for which this permit is issued,I shall employ parsons subject to workman's compensa- tion laws of California." The applicant m call far all req irad inspections. Complete drawing o averse side. •� Date: r . r Signed Title :.. I i1=0R DEPARTMENT USE ONLY /` � Application Accepted by /' I Date (� Area + Pit or Grout Inspection by !! Date Final Inspection by Date `� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 V Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { . t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO ' aEHt3-241REV.t/nsf EH 10-28 I