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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '�. (Complete in Triplicate) q 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. r City Lot Size PM Job Address 1 Mit 14.I� e� Vdltl��i) �I`+. Address Owner's Name Phone Contractor +� ay�� Address 6 A" icense No. Phone TYPE OF WELL/PUMP: NE WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION It/ SYSTEM REPAIRS OTHER DISTANCE TO NEAREST: SEPTIC.TANK, SEWER LINES DISPOSAL FLD. PROP. LINE C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack Specifications , ❑ Tracy Type of Casing 'Public 1-1 Other 1, (-1 Delta Depth of Grout Seal Type of Grout —.--- I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done L. ;Z a Well Destruction El Well Diameter + Sealing Material (top 501 Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION l 1 DESTRUCTION ( 1 (No septic system permitted if public sewer is r iE available within 200 feet.) r Installation will serve: Residence Al Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r f PKG. TREATMENT PLT. ❑ Method of Disposal (`6 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED. ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line' DISPOSAL PONDS El I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawsJan 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 shalt not l employ atonh manner as to'become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signaturecertifies tcertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion lawsThe applior all eq sired ins tions. Complete drawing a a side. } Signed X Title: Date: FOR DEPARTMENT USE ONLY ] J Application Accepted by I:" Date --�� Area Pit or Grout Inspection.by Date Final Inspection by --°m Date' ::� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 C 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 CKCASH RECEIVED BY DATE PERMIT-NO. +.EH13-24(REV.rinsl /ev 1 O 90--77- j EH 14-2e i