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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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �eqc, CityLot Size ` PM Owner's Name _� YA 4 �/72 Address ' Phone Address PO (a License No��—Phone + "7 7 _7 TYPE OF WELL/PUMP: NEW WELL L7 WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INATAI-I.ATION r-T SYSTEM REPAIR (I OT1111" r'1 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 I I Industrial ❑ Open Bottom 177 Manteca Dia. of Well Excavation Dia. of Well Casing I I Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications I I Public I-1 Other FI Delta Depth of Grout Seal __ Type of Grout I I Irrigation _ Approx. Depth I I 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 (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: A Water table depth _ SEPTIC TANK V1 Type/Mfg Sifp tF� Capacity �2-�� No. Compartments e PKG. TREATMENT PLT. f.1 t f Method of Disposal Distance to nearest: Well 1 d_ Foundation _�_ Property Line_t_ LEACHING LINE IVNo. & Length of lines � _ Total length/size (.oY FILTER BED 11 Distance to nearest: Well Foundation _ Property Line_. SEEPAGE PITS I I Depth Size .— Number SUMPS I I Distance to nearest: 1 Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di§trict. Home owner or licensed agent's signature certifies the following: "I cettify 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." ti 'Tile applicant must cal�fo all requir ins ctions. Complete drawing on reverse side. Signed X—Attu Title: I: .GV r Date: F DEPA ENT E ONLY Application Accepted by Date tea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments. Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O 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 RECEIVED BY DATE PERMIT'NO. INFO C SH EH 1324(REV rias) r 37 Ba EH 1426 /� / Is .0 •�'. OdO