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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ,pplication 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 lade 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 ocal Health District. ob Address �• 0L.; Cit/-P-C {Nf1`D rdo Lot Size -i l PM y wner's Name Address 7cz. ontractor � " Yf Address C XX 1/3 tLiNo.3t PhoneL� 't'• YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ISTANCE 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 I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ( Other n Delta Depth of Grout Seal Type of Grout Irrigation _-_ Approx. Depth I I Eastern Surface Seal Installed by � .pair Work Done ❑ Type of Pump H.P. ^^ `� State Work Done _ ell Destruction ❑ Well C16eter Sealing Material (top 50') n Depth Filler Material (Below 501 'PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ( j vl n Installation will serve: Residence_ Commercial available within 200 feet.) _ Other v 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth PTIC TANK ❑ Type/Mfg Capacity No. Compartments G. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ACHING LINE ❑ No. & Length of lines Total length/size TER BED ❑ Distance to nearest: Well Foundation Property Line =PAGE PITS I I Depth Size Number MPS ❑ Distance to nearest: Well Foundation Property Line ;POSAL PONDS F] areby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and s and regulations of the San Joaquin Local Health District. -ne 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 )loy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ifies 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- laws of California." applicant m all f r all reqried inspections. Complete drawing on reverse side Title: �_ C 'J�si Date: n- FO DEPARTMENT USE ONLY �i ication Accepted by (^,., ��a Date Area r Grout Inspection by Date Final Inspection by / Date L —tional Comments: k 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 cant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT NO. :V.1/851 �l� �-• a-�-1��11 l �OI �( wp