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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED i (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 descrilbed. 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. �+ 1 �1 ocxal� bCLS ��t�Of� I, Job Address City L-d Lot Size PM Owner's Name Address I� p hone Contractor - AddressIcense No. L r TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE ACEMENT E2 DESTRUCTION C1Phane f 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER J�o-I �-+��i-r I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r i DISPOSAL FLD. PROP. LINE 634 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMIPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing Public VC, II M l Specifications' f ! Other ❑I Delta Depth of Grout Seal -Ji Ty a of Grout a I i irrigation --Approx. Depth I 1 Eastern Jak Surface Seal Installed by ' i Repair Work Done ❑ Type of Pump H.P. ;I State Work Dnne ?�cn e�Il�DesRtruction � p Well Diameter Sealing Material (top 50') �I Depth =�� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I"I REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is Installation will serve: Residence's available within 200 feet.) I� Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I, { SEPTIC TANK- 0Water table depth Type/Mfg Capacity No. Compartments IM. PKG. TREATMENT PLT. p 1„ Method of Disposal V} Distance to nearest: Well FoundationI Property Line i i LEACHING LINE ❑ I f No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line k SEEPAGE PITSI` i I Depth Size Number � r SUMPS L-! Distance to nearest: Well DISPOSAL PONDS Ll Property Property Line `. 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 t certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to tion laws of California." `� persons subject to wiirkman's compensa- The applicantust call for all required ins pe ns. omplete drawin art re she s de �[{C 4 Signed XI� Title: Date: FOR DEPAPTMENT U E ONLIP G c CA- Application Accepted by C acrd Cc„rlg Date -g7 Area Pit or Groutspection by Date/ C _ /�!N Final Inspection by (Date Z 16—V Additional Comments: ❑ Stk 466-678f ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-6385 Applicant- Paturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 uP42�L7 rv.� Cv12t,. Qc4 FEE �ua. IPERMIT INFOAMOUNT DUE AMOUNT REMITTED SHBYOA7E 'NO.EH 13-24 IttEv,i i q 5f (��EH to-28J �ro f