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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 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. �{, Joh Address City !�') Lot Size PM Owner's Name Y^ SirT,�i lv Address `„ _ Phone ] Contractor's Name ro License No. -S9 t S 713 � TYPE OF WELL/PUMP: 130 NEW WELL Phone WELL REPLACEMENT ❑ DESTRUCTION ❑. -PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC•TAN'K'"�� SEWER LINES ,7� '' -DISPOSAL FLD.�Z PROP.-LINE--6- FOUNDATlON �AGRICULTURE WELLt r — OTHER WELL 1�PIT /SUMPS _. INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTI.ON SPECIFICATIONS-- A ❑ Industrial '� , Open_Bottorri ❑ Manteca Dia. of Weli Excavation �5ve Dia. of Well Casing Domestic/PrKate I Gravel Packt ❑ Tracy Type of Casing < Specifications I f Bj d ❑ Public k ❑ Other ",,❑ Delta Depth of Grout Seal ❑ Irrigation ` Type of Grout g _Approx. Depth _,q---Eastern,. �'�� Surface Seal Installed by Repair Work Done , ❑ Type of Pump H.P' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top Depth S `N, Filler Material ow 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION q (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial 4 Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth^k SEPTIC TANK ❑ Type/Mfg Ca act P tY No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total'length/size ' FILTER BED ❑ Distance to nearest: WellFoundation Property Line .10 SEEPAGE PITS ❑ Depth Number j, SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not x 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 certifythatin the performance of the work for which this permit is issued, I shall em to tion laws of California." p y persons subject to workman's compensa- The applicant m c I for all required J'Xislwctlons. Complete drawing on reverse side. Signed Title: A Date: FOR DEPARTMENT USE ONLY Q �` Application Accepted by Date - � ' l9 Area f f t Pit or Grout Inspection Date + 1 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O 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 96201 � 1 FEE AMOUNT DUE AMOUN"REMIT.TED INFOrH :� RECEIVED BY DATE PERMIT'N0. + EH 1324[REV.10/83Y - EH 14-26