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APPLICATION FOR PERMIT tJ 1(`-UUU SAN JOAQUIN LOCAL HEALTH DISTRICT g rrz, 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (249) 466-6781 � I PERMIT EXPIRES 9 YEAR FROM DATE ISSUED t40V 21987 5 (Complete in Triplicate) ��ppHEALTH YrL�'h EN A Application is heleb made to the San Joaquin Local Health District for a permit to construct and/or install the woNrlcation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a f t �f�� 'S'�it Joaquin Local Health District. Job Address 3 City Lot Size PM I Owner's Name ^� 1 AddresX I`l -,a - 'w f"�� Phone I I Contractor �'f" � '� Address -_Alt License Nol b f'flone TYPE OF WELL/PUMP: NEW WELL ❑ If- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL—- - ._OTHER.WELL. - PITSISUMPS.. _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation Dia. of Well Casing 1yDornestic/Private D Gravel Pack ❑ Tracy - --Type of Casing Specifications ['1 Pubic ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 63' Type of Pump H.P. _ State Work Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION Il [No septic system permitted it public sewer is available within 200 feet.) s? Installation will serve: Residence Commercial— Other Fr 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 lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � S SEEPAGE PITS 11 Depth Size Number / SUMPS L-I Distance to nearest: Weli Foundation. Property Line 1 hereby certify that I have prepared this application and that the work will'be doneWin 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."Contractor's 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." rr The applicant must call for all reqjuirej inspection Complete drawing on reverse side. G Signed X � TitEe: Date: —/ �j� U �/ FAR DEPARTMENT USE ONLY Application Accepted by Date Area / Pit or Grout Inspecti b Date Final Inspection by>�, Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CI 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 REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.1/k 5) �QQ p+► _ �� —2,96 EH 14-26 `–/lr /// J