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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED" (Complete in Trlpkate) :: `�'` 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 Ryles and Regulations of the San Joaquin Local Health District. w Job Address _ �3 — (�rVt JVL'0 - Cid Lot Size Owner's Name dress _ - - Phone - Contract& Address i2to r L l� License No, 396 Z- Phon -'_arf TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El— PUMP PUMP INSTALLATION '- SYSTEM REPAIR"❑ OTHER ❑ 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 `Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ElIrrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work pone C1 Type of Pum H.P. State Work Done, "r Well Destruction ❑ Wel! Diameter: Sealing Material (top 50') r Depth Filler Material (Below 50') OQ TYPE OF SEPTIC WORK: NEW INSTALLATION, ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is J; { *` available within 200 feet.) Installation will serve: Residence_ Commercial's" Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg '.Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lineslot--length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property-Line I SEEPAGE PITS ❑ Depth -Size Number SUMPSa ❑ Distance to nearest: Well Foundation Property Line DISPOSAL 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."Contractors 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 applicant must call f, r all required_i spections. Complete drawing on reverse side. Signed Title: . Date:a � f' l W FOR DEPARTMENT USE ONLY Application Accepted by Date _y ` 2` U� Area i Pit or Grout Inspection by ate Final Inspection pie i Additional Comments: f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTEDCK INFO ASH RECEIVED BY DATE PERMIT`NO. F + EH 13-24(REV.1/85) - - - /. p ?I EH 1428