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' A1C APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT +' 1601 E. HAZE.T ON AVE., STOCKTON, CA rf, e Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ' } .7Z k1 `� �l�Ge-,- City `f ' Lot Size PM Owner's Name « b Phone ` Contractor Address License No. Phone v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"7 Public ► ❑ Other Ll Delta Depth of Grout Seal 1T7 ��+�in'� Type of Grout _- s I I Irrigation _ _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material Ieelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Insta ill serve: Residence_ Commercial_ Other Number of living uni Number of bedrooms Character of soil to a depth of 3 e �atertable N SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT P. ❑ # Method of Disposal Distance to nea i Well Fo �on Property Line r i � 1 LEACHING LINE No. & Length of lines Tota /size FILTER BED ❑ Distance to nearest: Well Foundation Property a SEEPAGE PITS l I Depth t Size Number SUMPS 6—Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 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." The applica u II for all re uir d inspect ons. Complete drawing on reverse side. I Signed Title: Date: s FOR DEPARTMENT USE ONLY Application Acceptedby _. Dater +- '2 �v Area Pit or Grout Slnspectio b Date Final Inspection by Date (� Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMiT'NO. INFO 11 C I a..EH 13-24IREV.ii851S.� "1 11•�.� 6 e� ��y I EH 14-28 f