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APPLICATION :FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-it ro,i ..,(Complete in Triplidate) �0 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d kation is l made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rules San Joaquin Local Health District.:n_ : t' � ., i - r ti �- ERS �Y, Q Job Address . !`�.57Y'f^ C��4 City . lr Lot Size, �d �✓ PM "t - i Qs, Owner's Name jl']D�'1'[Gl.'S ,t�JjGZ.117ti _ Address _�f�� _��'Ll phone 9Q .t Contractor Address — License No. a / Phone TYPE OF WELL/PUMP: 11 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ VVV DISTANCE TO NEAREST: SEPTIC TANK IDS} SEWER LINES = DISPOSAL FLD. PROP. LINE FOUNDATION f AGRICULTURE WELL` �{ OTHER WELL PITS/SUMPS �... INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom T ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ^ Domestic/Private Gravel Pack I Tracy Type of Casing �I'C; Specifications ❑ Public ❑ Other + ❑ Delta Depth of Grout Seal �� Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by hA Repair Work Done ❑ .Type of Pump H.P. Sta a Work Do Well Destruction ❑ Well Diameter Sealing Material (top 50') 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.) Ins ill serve: Residence_ Commercial— Other Number of living un7depth umber of bedrooms Character of soil to 3 feet: Water table depth SEPTIC TANK pe/Mfg Capacity No. Compartments PKG:TREATMENT PMethod of Disposal f Distance to nearest: Well Foundation operty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line , SEEPAGE PITS ❑ Depth R Size .Number w. SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cerfiN that f Hage prepared-this application and that the work will-be`ddne iri accordance witfi 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 }1 employ any person in such manner as to become subject to workman's compensation taws of Californ'ia." Contractor's hiring or sub-contracting signature I 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- I' tion laws of California." The appli an ust call for all requir inspections. Complete drawing on re a sic . f Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date v �!! / Area Pit or Grout Inspection Date Final Inspection by Date 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 FEEINFO 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. 1 + E!113-24 iREV.1/85) EH 14-26