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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA .a Telephone 12091 466-6781 ry 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. It �� f�� Citys�e - Size PM Job Address _ • Owner's Name 1 .1 �r"�"� `� d�ess ! q__0�, Tk�ir_ `t Phone ��f Contractor's NameJA 1C . ""ARkense No. + Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTAE ATION'"Q � 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 j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta 4 Depth of-Grout Seal Type of Grout ❑ Irrigation x ��4pprox. De �- sterni �- N-Su ce Seal�nstalled by Repair Work Done h?'� Type of Pump � � H.P. State Work Done {{vv Well Destruction ❑ Well!Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF-SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:— Water table depth SEPTIC TANK ❑ Type/Mfg,- a Capacity ` No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well I Foundation Property Line U SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Liner DISPOSAL PONDS ❑ 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(Fortify that in the performance of the work for which this permit is issued, I shall not ...employ any poison in.such-manner:as-to-become subject to-workman's compensation•laws•of-California.".Contractor's hiring or sub-contFacting-signature---� , certifies the following:"1 cereinformance of the work for which this permit is issued, I shall employ persons subject to workman' compensa- tion laws of Califor �/ nia." 4 1 The applican s call f r awin .on re rse e, t Signede: Date:IDEPARTMENT USE ONLY O/ 2- Application Accepted by Date Area t, Pit or Grout Inspection by Date Final Inspection by Date _ - fid' Additional Comments: ❑ Stk 4664781 ❑ 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 11 FEE AMOUNT DUE IA AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT"NO. INFO + EH 13-24 IREV.101931 EH 1428 �� o