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APPLI 'ATI PERMIT SAN JOAQUI LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRE i YEAR FROM DATE ISSUED i (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 incompliance 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 Distridt. Job Address 40 Gl. t City of Size PM , v E Owner's Name i d Address Phone wa Contractor's Name Q License N YJ c74� c3 Phone :j:D [ 3 g'y TYPE OF WELL/PUMP: i1 NEW WELL ❑ WELL REPLACEMENT OF 9byi ESTRUCTION ❑ PUMP INSTALLATION ❑ i ' SYSTEM REPOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES° FLD. PROP. LINE FOUNDATION — AGRICULTURE WELL W.+ ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTINS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex ❑ Domestic/Private. ❑ Gravel Pack ❑ Trac Dia. of Well Casing Y Type of Casing ❑ Public I Specifications ❑ Other ❑ Delta l Depth of GroutType of Grout ❑ irrigation } —Approx. Depth ❑ Eastern Surface Seal Iny F Repair Work Done ,❑ Type of Pump ° H.P. State Work Done I iWell Destruction Well Diameter t Sealing.Material (top 50') S moo_0,(c „ { Depth n Filler Material (Below 50') ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑I� available within 200 feet. REPAIR/AD ITION 1❑ DESTRUCTION ❑ (No septic system permitted if public sewer is : / --�— Installation will serve: Residence_ Commercial_ Other Number of living units: umber of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ y II Method of Disposal Distance to nearest:, Well Foundation Property Line LEACHING LINE + ❑ No. & Length of lines + Total length/size FILTER BED 1 ❑ Distance to nearest: .,Well Foundations ' Property Line , SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 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 j employ any person in such manner as to become subject to workman' compensation laws of California."Contractor's hiring or sub-contracting signature k{ certifies the following:"I certify that in the performance of the work fo which this permit is issued, I shall employ 1 tion laws of California." _ J P Y Persons subject to workman's compensa tR ,.,�,.. The applicant must call for all requir inspections. Complete drawingon reverse side. Signed Title: Date: FOR DEP)kRTMENT USE ONLY Application Accepted by 3 Date Area ©� Pit or Grout Inspection by Date 7:Final Inspection by Date Additional Comments: Il. >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 INFO CASH RECEIVED 6V DATE PERMIT NO. ;Y EH 13-24(REV.10/83) 1 Q �/� 6 } -�EH 14-26 O - C�-� o _... :M.