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APPLICATION FOR PERMIT 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 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 Cou my Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations ofhe San Joaquin Local Health District. el Job Address © 'y CityLot Size �vly `o PM /. , Owner's Name Address ! �'y Phone c47 2� Contractor's Name f n License No. V Phone TYPE OF WELL/PUMP: NEW WELL IT WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 SPECIFICATIONS k ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public El Other 1 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx.1Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done: Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Belo 50') ;V TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 9 DESTRUCTION' (No septic system permitted if public sewer is w A e� r i1 av�ilble hin 200 feet.) Installation will serve: Residence_` Commercial Other CX Number of living units: Number of bedrooms__ Character of soil to a depth of 3 feet: Water table.-depth SEPTIC TANK Type/Mfg apaciNo. Compartments PKG. TREATMENT PLT. ❑ Method.of pis osal Distance to nearest: Well Tc. Foundation_eo Prbperty LineV LEACHING LINE ❑ No. & Length of lines To lI length/size -' FILTER BED ❑ Distance to;nearest: Weil Foundation_Z S Tl' Property Line � I SEEPAGE PITS LlDepth • Size N tuber SUMPS Q Distance to'nearest: WeII Foundation� _ PropertyLine DISPOSAL PONDS ❑ A 1 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 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_" I The applic t must call for re 'red ins" ctlons. Complete drawing on reverse side. Q Signed Title: Date; 3- " (� _ FOR DEPARTMENT USE ONLY Application Accepted by [ .-96 Date Area ooLi � Pit or Grout Inspection by G r�A-- Final Inspection by ate i ii Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 AMOUNTREMITTED CK# RECEIVED BY DATE PERMIT•'N0. INFO CASH + EH 14-24[REV.10183) -11W—7 0Ig1i -7 /1 �� 63 EH 1426 C7'� - ( a0