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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4,_ C` City 't �AQ-e\ Lot Size D� V-C11PM —art Owner's Name _ o r v`1"�CAddress 22 c SL,16A r1. Phone —3)7 l Contractor's Name S 1, 'UICw �rt1�` '9 LiBense No. PhoneM TYPE OF WELL/PUMP: NEW WELL Q—. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP_NSTALLATION 9--' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 20(1t)' SEWER LINES 1-000 ' DISPOSAL FLD. PROP. LINE FOUNDATION � AGRICULTURE WELL n OTHER WELL PITS/SUMPS I TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;3?11Inyius'trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -Domestic/Private 0.Gravel Pack ❑ Tracy Type of Casing ' Specifications �P � ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation rl r p - Type of Grout 9 4 q�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. D State Work Done 17 ��r LLLDDD Well Destruction Well Diameter Sealing Material (top 50') EF— Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑1. 1No septic system permitted if public sewer is available within 200 feet.) Installation will serve:' Residence— Commercial_ Other Number of living units: ! Number of bedrooms Character of soil to %a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line`' i LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line f 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents 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."Contractors 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." T The applica must fgor, req fired inspections. Complete drawing on reverse side. Signedi1 Sc. Title. Date:�►r`s' 3 1 t RDA M SE ONLY Application Accepted by Date Area_e3 Pit or Grout Inspe o y 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 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH EH 13-24(REV.10/83) EH 1426 CCCJJJ„'!lIJJJ CJ _ � L I