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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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.593 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. F1 Job Address C, � City f-lize PM �4 Owner's Name Address tn' Phone r k Contractor 6E; Address License No: V �. Phone �d 54 PE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION 11F. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ IDISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J k .3 INTENDED USE TYPE Of WELL PROBLEM AR STRUGTION SPECIFICATIONS ❑ Industrial ❑ Open-Bottom ❑ Manteca Dia. of a ation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f t ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by �epair Work Done ❑ Type of Pump H.P.. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filer Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is D r available within 200 feet.) { r Installation will serve: Residence L—Commercial_ Other Number of living units:4.__ Number of bedrooms 3 . Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I:�__Fype/Mfg Ci-)Ncre_tE Capacity—_12NIND No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINEM—No. &Li Total length/size L/a F FILTER BED ❑ Distance to nearest: Well Foundation PropertyLine SEEPAGE PITS M--Depth a-5 -Size NuMber I SUMPS © Distance to nearest: Well Foundation Q_ Property Line S DISPOSAL PONDS El 16 Li t— 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 f 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,11 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature c ifies the following:."I7all at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- y ti of California." The applican st call fui Jinsctionn. oate dna 'ng on reverse side. g � Date: 5'r n rtle: j FOR DEPARTMENT USE ONLY 1� Date plication Accepted �/ �`/7`{G Area y 1 Pit r Grout Inspecti by - Date ! o Final Inspection by Date rr�le Additional Comments: a ❑ Stk 466-MI ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-CW ,I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE AMOUNT REMITTED CA # RECEIVED BY DATE PERMIT'NO. F *EH 13-24 MEV.1/85) EH 1428 i