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APPLICATION FOR'PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT' 31 1601 E. HAZEL 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'tonstruct 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. i Job Address / City Lot Size PM [ r CQ Phone Gee /!s led I Owner's Name 1 vlh 1� D CLt 0.: Address Contractor ` Address ZZ 4x l -fZ 71 _License No. � Z 73 Pho e TYPE OF WELL/PUMP: NEW WELL EJ 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 CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public (-I Other F1 Della Depth of Grout Seal Type of Grout _ t I Irrigation —_ Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done (_7 ype of Pump —.d. H.P. I State Work D e_ Well Destruction rWell Diameter — Sealing Material (top 50'l Ay A Depth XRR Filler Material (Below 50') '-.- ----. TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK n Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E-I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines I Total length/size FILTER BED E:1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El i I hereby certify that 1 have prepared this application and that the work will be done in accordance with San in y e laws, and rules and regulalio the San Joaquin Local Health District: "J Home own r ticensed ag s signature certifies the following: "I certify that in the performance of the w for ich s is i ed, I shall not employ a person in such man or as to become subject to workman's compensation laws of California."Co r r b-con cting signature certifies he following: "I certify t t in the ace work for which this permit is issued,I shall employ persons subject to workman's compensa- tion la s of California The ap licant must all f regt'e c plata swing on rev side. Signed X le: Date: r� A /FOR`DEPARTMENT USE ONLY t '�Gei.'B'L� 1 i Application Accepted by Rate Area Pit or Grout Inspection by Date Finpl Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ anteca 823-71 ❑ Tracy 835-6385 amu _ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, SIV., CA Eii FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO CASH 1 . EH 1334(REV.+i mt.) EH r,,-M