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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is.hepeby 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: j-Vpp € Job AddresSK ',�I _1 �. / ) City VrLot Size PM Owner's Name �i _ Address D � • hone ContractsddressdM�f License No. Phon I TYPE OF W LL/PUMP: NEW WELL ;K WELL REPLACEMENT d DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 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 SPECIFICATiOlIS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava 'erI Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F" Public n Olher n Delta Depth of Grout Se i A ype Grout _ IYI E ri,at'oON I pprox.,Depth I ] Eastern Surface Sea! Instalied by r RT' r o e C7 Type of Pump H.P- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') f Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (:) REPAIR/ADDITION L] DESTRUCTION I I {No septic system permitted if public sewer is ,� f available within 200 feet.) Installation will serve: Residence J Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:I Water table depth R� SEPTIC TANK (7 Type/Mfg: Capacity_ No. Compartments PKG..TREATMENT PLT. ❑ IMethod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED L1 Distance t nearest: Well Foundation Property Line I SEEPAGE PITS I 1 Depth I Size SUMPS Number L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ P i 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 I 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 N 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 G ' rnia." I The .pp tgwst call f all r ired ins Gom late drawing on reverse sid Signed X FEB R 1988 Title: I� Date: f a+ V IJE?V FOR DEPARTMENT USE ONLY Application Accepted by Date � � � Area Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma tete 823-7104 0 Tracy 835-6385 � Applicant - Return all copies to: Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95.201 FEE AMOUNT DUE AMOUNT REMITTED INFO #� C SH RECEIVED BY DATE PERMITNO, p //JJ h + EH 13-21[HfV.r i x s1 rrLtl.� � �y� !y,"t!✓] EH 11-28