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APPLICATION FOR PERMIT >� � ( SAN JOAQUIN LOCAL HEALTH DISTRICTn 1601 ,E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J . j _- .(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, Job Address G �j of Size PM Owner's Na ddress v�_-CAPhon�e U Contractor Address License No. Phone TYPE OF-WELL/PUMP_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTI SEWER LINES DISPOSAL FLD. PROP. LIN FOUNDATION --7=AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ` Dia.-of-d—W611-Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack T-ra;y Type of Casing_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by— pp y ff--11 Repair Work Do Type of Pump H.P. State Work Done W Well D ction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is avail bie within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK )e Type/Mfg Capacity No. Compartments F PKG. TREATMENT PLT. ❑ Method of Disposal r - Distance to nearest: Well Foundation Property Line --LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to,nearest: Well Foundation Property Line �_.. _ — -• -- _ . -.: Tom-- --T ..._._ 4-- SEEPAGE PITS �,f Depth Size Number SUMPS ❑ Distance to-nearest: Well Foundation Property Line l DISPOSAL'PONDS e ❑ j 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. j 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 I 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 applic st call fora re uir d inspections. plate drawing on .verse side. Signed Title: tiv /[X/�✓ Date: . d`' FOR DEPARTMENT USE ONLY j Area f t t Application Accepted by Date Pit or Grout lnspectio Date Final Inspection by Date. — ; Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 d Manteca 823-7104 , ❑ racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton,Ave., P.O. Box 2009, Stk., CA 952TV iFEE AMQUNT DUE AMOUNT REMITTED CK IF RECEIVED BY DATE PERMIT'NO. INFO C� + EH 13-24 iREV.r/as} EH%28 --