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lop APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA J Telephone (209) 466-6787 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F, ', (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a r. made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 7862 for wail/pump and the Rules and Regulations of the San Permit to construct and/or install the work herein described This application is Local Health District. Joaquin _ Job Address •�.4 � City� /�� Lot Size Owner's Name PM�"' Address s / Pfion .� Contractor Address �+r TYPE OF WELL/PUMP: NEW WELL ❑ icense N Phona� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ — SEWER LINES � DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL INTENDED USE OTHER WELL PITS/SUMPS P_E OF_WELL. P,R08L_EMAREA CONSTRUCTION,SPECiF_ICATIONS..� El Industrial 0 jOpen Bottom •. ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑.Gravel Pack ❑ Tracy T Dia. of Well Casing ❑ Public .� ., TYPO of Casing 1.Specifications ❑ Other -;;O Delta Depth of Grout Seal ❑ Irrigation —'—Approx. Depth ❑ EasternTYAe of Grout Repair Work Done LlTypeTYpe of Pum Surtace Seal Installed by i Well Destruction El �H.P. State Work Done Well Diameter Sealing Material (top 50') i Depth _,Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTIO Mtic L se A system permitted if public sewer is -Installation will serve: ResidenceCommercial _ 4 Other ilable within 200 feet.) Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: 3 1 SEPTIC TANK ❑ Type/Mfg ? Water table depth PKG. TREATMENT PLT. ❑ jCapacity— No. Compartments Distance tojnearest: Well +� �, 1 , Method of Disposal ' •: Foundation Property Line LEACHING LINE ❑ iNo. & Length of lines FILTER BED ❑ [Distance to nearest: Well Total length/size Foundation Property Line } SEEPAGE PITS ❑ Depth j ,size Number SUMPS ❑ bistance to nearest: Weq DISPOSAL PONDS [] Foundation Property Line ' 1 hereby certify that i have prepared this application and that the work will be done•in-accordanbe with San Joaquin county ordinances ; rules and regulations of the San Joaquin Local Health District. state laws, and Nome owner or licensed agent's signature certifies the following: "I certify that in the Pertarmance 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 certifies the fallowing: "i certify that in the Performance of the work for which this tion laws of California." Permit is issued,I shall employ persons subject to workman's corn t pensa- The applicant t call for all required inspections. Complete drawing Signed Title, • on re side. ' i / Q ' Date: ! o FOR DEPARTMENTUSE ONLY Application Accepted by ' Date Area Pit or Grou I spection LbD � � x �'�Date�� - - 1 Final Inspection by f bate Additional omments: k Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 Applicant- Return alt copies to: Environmental Health Permit/Services 1601 EO azreiton Ave., Box 2009, Stk., CA 95201 FEE INFO ' AMOUNT DUE AMOUNT REMITTED CK EH 13-24 RECEIVED 8Y DATE PERMIT'NO. EH 14-28 H + fREY.t/a51 �� V� _ / r�