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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address i�• � --- City Lot Size PM Owner's Name . Address Phone dresContractor License NPhone o.4fiO/oFS9 Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES F DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL -'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -1Manteca Dia. of Well Excavation Dia. of Well Casingr ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' ` Type of Casing Specifications w ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout R ❑ IrrigatidN'.`, —,--Approx. Depth ❑ Eastern Surface Seal Installed'by J' Repair Work�Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter' Sealing Material {top 501 Depth Filler Material (Below k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ No septic system permitted if public sewer is � available within 200 feet.) rt Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: d Water table depth I SEPTIC TANK ❑ Type/Mfg .city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance td nearest: Well Foundation Property Line a I LEACHING LINE ❑, Not & Length of lineseo Total length/size FILTER BED ❑ '"Distance to nearest: 'on Property Line s ' +. SEEPAGE PITS a ❑ -Depth Size mbar SUMPS ED Distance to near t: Well 4-i Foundation rProperty Line 7ZA� DISPOSAL PONDS ❑ i 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. I 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, 1 shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sutrcontracting"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 workmaiN compensa- tion laws of California." ' The applicant ust call for required 'nspections. Complete drawing on reverse side. Signed w Title:- � d (� � Date: / r -• FORD ARTMENT USE ONLY Application Accepted by Date Area i Pit r Grout Inspection by Date�3A A)-7 Final Inspection by r +� i itional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca 823-7104 ❑ Tracy 8355-6385 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 N0. , INFO _ (� CASH t1 + EH 14-24 IREV.1/85) �—I( - p� /' 11 r-� EH 1426 {�.J l�� ` t