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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT } 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. City 1 !V Lot Size �z PM Job Address p f Owner's Name ` Address t �e Phone Contractor N Address t`^—` License No. Phone TYPE OF WELL/PUMP: ANEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 s ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other 1 17 Delta Depth of Grout Seal Type of Grout—.-- I rout —I I irrigation -Approx. Depth I l Eastern Surface Seal Installed by O r' _ Repair Work Done LJ Type of Pump H.PState Work Done Well Destruction F1 Well Diameter Sealing Material (top 50'1 - Depth I Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADOITION 1 I DESTRUCTION ! I (Na septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth o t: Water table depth SEPTIC TANK. p Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑' Method of Disposal 13istarice to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size \vr FILTER BED ❑ Distance to nearest: Well Foundation Property Line iI r SEEPAGE PITS F 1 Deptfil Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 Diktrict. r 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 4 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 shallemploypersons subjdct to�yorkman's compensa- tion laws of California." I L�'r �`}—� tl �'�r1 The applicant m st c II for u r ns. Complete drawing on reverse side. J Signed X Title: Date: FOR DEP TMENT USE ONLY 4 Application Accepted by Date �' Area Pit or Grout Inspection by Data Final Inspection by r `� Date �� t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 .❑ 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 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO a.EH 11 24 1/85) EH 14-29 •�•