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C 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 s (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 1pump and the Rules and Regulations of the San Jeaquin Local Health District. f CityLot Size PM Job Address / L r-' I -.] Phone `^ ,Owner's-Name Address { t License No. -/ Phone Z i Contractor's Name � E TYPE OF WELL/P MP: b NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (DISTANCE 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia,-of Well Excavation Dia. of Well Casing 'Ll Domestic/Private L3 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public El Other l ❑ Delta Type of Grout Depth of Grout Seal ElIrrigation ---Approx. Depth C1 Eastern Surface Seal Installed by Repair Work Done ElType of Pump I H.P. Stats Work Done r i w Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION•❑r DESTRUCTION ❑ (No septic system permitted if public sewer is J __ available within 200 feet.) �1 � Installation will serve: Residence�� Commercial� Othe�-' �� � 4 I Number of living units: Number of bedrooms ! Character of soil to a depth of 3 feet:'I ' Water table depth I El Type/Mfg Capacity ti- No. Compartments PKG. TREATMENT PLT. ❑ i,* , ,: .-. .,.-�'I Method of Disposal, Distance to nearest: " Well"� Foundation Property'Line 4 c� . . . LEACHING LINE ❑ No. & Length of linesTotal length/size _F FILTER BED 13 Distance to nearest: Well Foun i ' n Property Line r SEEPAGE PITS ❑ Depth. F Size Number SUMPS ❑ Distance to nearest: Well ndation Property Line `~ ` DISPOSAL PONDS El I J F 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. , r 1 'Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this It 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 I certifies the following:"I certify that in the performance of the work"for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f . 11 required inspections. C plate drawing on rave ---4-.�y-- — Y 1 Title: — Date: Signed OR DEPARTMENT USE ONLY Application Accepted by — Data .a Area b ` iI� �n �, t Pit or Grout inspection by 6 Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 1-] Manteca 823-7104 ❑ Tracy 835-6365 a-*C, L, s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 35201 r k ` 4 s F - FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. Y y. € , INFO ` E +EH 13=24 MCV-10/83) !`'..., .. ,. s _ ....... C) t' Q - '� .a /r.�Lb/�6. -��k i EH 14-28 . . '