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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 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �CL City Lot Size x 0 PM �S��R —"��..� _ <, Phony • 7Z Owner's Name FAddress ContractoRb Address 10004 �z _License Nom Phone .TYPE OF WELL/PUMP: }__ _,NEW WELL 0w,.. . .._ _WELL REPLACEMENT ❑ DESTRUCTION ❑_ � PUMP INSTALLATION ❑ 1 SYSTEM REPAIR © OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a '7]ISPOSAL FLD. PROP. LINE O FOUNDATION '""A6RiCULTURE WELL . A t 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 '�' r❑ Domestic/Privates�A ❑-Gravel'Pack ---❑ Tracy - Type of Casing Specifications _ M Publica.\ ; HCl Delta Depth of Grout Seal Type of Grout 1 1 I I Irrigation ---Approx. Depth 'I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump - - H.P. -State Work Done �q iii`"a'.'t b i !•., Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth i Filler Material 18elow 501 �• S •` ' TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION/ DESTRUCTION I I (No septic system permitted if public sewer is , / available within 200 feet.) V Installation will serve: Residence Commercial_'"Other # Number of living units: Number of bedrooms `Character of soil to a depth of 3 feet: 'w Water table depth SEPTIC TANK ❑ Type/Mfg No. Compartments Z i PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ,Vlf No. & Length of lines` - - ` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line /SEEPAGE PITS l I Depth �� Size ��1 Z A!4!.ti Number c' �'�.s ef'w� v;,t 'SUMPS lgie Distance to nearest: Well Foundation ,2b�-30� Property Liner.._._.4�40 1 DISPOSAL PONDS ❑ .l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Qrdinances, state lavys, and L rules and regulations of the San Joaquin Local Health District. f11 .''I �,r. "k- 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,,) 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 issued';' shall employ persons subject�to workman's.cbmpensa- tion laws of California." The applicant m st call for all equired inspections. Complete drawing on reverse side. J �7 Signed Title: -_ Date: rd ��✓ FOR DEPARTMENT USE ONLY Application Accepted by Date `-' ' �` � Area B Pit or Grout Inspection by bate. Firial Inspection by Date Additional Comments: � - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca: 823-7104 ❑ Tr cy 835--&385 f Applicant- Return all copies to: Environmental Health PeriM7Service,s 1601 E. Hazelton Ave., P.O:9ox 2009, Stk., CA 95201" EE INFO AMOUNT-DUE 1 tdUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. + EH 13-24{REV.1/95) EH 1428 531 611 Y!