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C APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT AUG 211984 1601 E. HAZELTON`AVE., STOCKTON, CA Telephone (209) 466-6781 SAN JOAQUIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DISTRICT (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address P" city Ot Size PM Owner's Name • [ Address Phone / N. Contractor's Name f <<µ - License No. Z _73 S4/ Phone 114646L TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ I OTHER El DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES -DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL 1 1*OTHER WELL _PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI6N SPECIFICATIOINS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �1SmesticlPrivate ❑ Gravel Pack 0 TracytDepth Type of Casingp Specifications ❑ Public ❑ Other ❑ Delta of Grout Seal �lType of Grout ❑ Irrigation —Approx. Depth ❑ astern urface°.deal Installed OtN Repair Work Done IP/ Type of Pump H.P.c State Work Done ' l Well Destruction E3Well Diameter k Sealing Material Itop 501 Depth t Filler Material Ieelow 501 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 fff I Number of living units: Number of bedrooms v Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Ir { LEACHING LINE ❑ No. & Length of lines Tota) length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ,�.... SUMPS EIDistance to nearest: Well Foundation _ Property Line _ DISPOSAL PONDS ❑ ` 'o, 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 employany pe neer as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t lowing: 'I certi that in the pert f; of work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la of Californi The a licant must r I requ' d i plate awing on reverse sid Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ��? r Pit or Grout Inspection by Date Final inspection by /ZdDate Additional Comments: / - /PfStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CARECEIVED BY DATE PERMIT'NO. INFO �y +EH 1324[REV.10!83} EH 14-26 _ _ -