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APPLICATION FOR PERMIT /] r SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone !2091 466-6781 Oct � . 19 ;PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SA 84 (Complete in Triplicate) Nf AST QUj'V //�� f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dl3s�� tion is made in complianc%with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations X,*,n Joaquin Local Health District. Job Address Ciaw� Lot Size PM a Owner's Name ddress Phone C� Contractor's Name License No. Q �l - Phone TYPE OF WELL/'UMP: ' NEWWELL:. �� °` WELL REPLACEME DESTRUCTION n PUMP INSTALLATION El SYSTEM REPAI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK!_ SEWER LINES DISPOSAL FLD. _ PROP-. LINE _ -_i6"_ --_i6"_ - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f �� ❑ Industrial ❑ Open Bottom lianteca Dia. of Well Excavation 416mestic/Private T16ravel Pack ❑ Tracy Type of Casing O Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation _— Approx. Depth ❑ Eastern Surface Seal Installed by C Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter Il Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION, ❑ (No septic system permits I available within 200 feet.) Installation will serve: Residence _' Commercial _ Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' i Water table depth SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,I Method of Disposal Distance to nearest: Well Foundation Property Line F ia. of Well Casing 12 -is pecifications , /Type of-3rout&A&Lif LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line public sewer is M SEEPAGE PITS ❑ Depth Size Number , SUMPS ❑ Distance to nearest: Well Foundation_ Property Line DISPOSAC 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 employ any person in'such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies 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- tion laws of California." , The appli ust-call for all equi inspections. Co Mete drawing n leve side. Signed Title: Date: FOR DEPARTMENT SE ONLY Application Accepted by ` DatArea r �i dr - Pit or Grout Inspection by Dat � Final Inspection by Date Adriitinnal Cnmments: ❑ Stk 466-6781 ❑ Lodi 369-3621 J ❑ 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 + EH 13-24 (REV. 19!83 EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. LA 3, a© ►3 �� � a/off -�3>I L