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APPLICATION FOR PERMIT R. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone. (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. Job Address ► ,.. ,.. - _ .� City Lot Size PM i Owner's Name Phone "" Phone Contractor Address icense No , Phone e� t TYPE OF WELL/P P: jNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P, U PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. "_PROP. LINE ` 1 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open 86ttom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications o- " 1-1 Public ❑ Other I F Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I i Easfarn "" --Surfiace Seal Installed't5y`;' ` Repair Work Donee ❑ Type of Pump H,P,. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IR' REPAIR/ADDITION I i DESTRUCTION I 1 INo septic system permitted if public sewer is r t available within 200 feet.) Installation will serve: Residence J— Commercial_ Other - } Number of living units: _�_ Number of bedrooms . 1 Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments } PKG. TREATMENT PLT. ❑ I z _ Method of Disposal Distance to nearest: Well�pf Foundation_ Property Line 1 LEACHING LINE ❑ Na. & Length of tines Total length/size f FILTER BED ` ❑ Distancer to nearest: Well Foundation Property Line C ..� SEEPAGE PITS C I Depth Size -7• l Number i SUMPS ❑ Distance to nearest: Well Foundation0-4-Property Line_- DISPOSAL PONDS ❑ 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, and l rules and regulations of the San Joaquin Local Health Di$trict. 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 shall employ parsons subject to workman's compensa- tion laws of California." y, r The applicant st call or II requi(,Z"inspections. o ete drawing onrr -fside. i Signed X Title: Date: I_Zhaj 47r FOR DEPARTMENT USE ONLY Application Accepted by Date 0 Area Pit or Grout Inspection by. Date Final Inspection by Date r 8lf Additional Comments: ❑-Stk -466-6781 0 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CKSH RECEIVED By DATE PERMIT"NO. ` V F +.EH13-24fREV.ii95) 17O C 1_ r `1 30 i f fe FFFF EH 14-28 /`" l