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APPLICATION.-FOR•PERMIT ' - SAN JOAQUIN LOCAL HEALTH"DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECF`1V Fn Telephone (209) 466-6781 MAY�. lnpq PERMIT EXPIRES 1 YEAR FROM DATE ISSUEIJI�gAN JOAQUIN COUNTY (Complete in Triplicate) NN��P��UBLIMMCFFHEALT��H S��E��RVII�C��ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install'tlie�woikTierelnLdescnbed.'ltiisSapp�lcation 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 1 'y Q 1/ _ D +OhR�_ City%d<_NIy1 Lot Size PM Owners Name MXJ& J�� * rress •O 49-A 1 ' Q 1 one Contract Address License No. 2� P11 n TYPE OF WELL/PUMP: NEW WELLK WELL REPLACEMENT ❑ DES,TRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER C)i W U 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 SPECIFICAT4IQNS l� C Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casin C Domestic/Private R<ravel Pack ❑ Tracy Type of Casing�- Specifications �o-G C Public . ❑ Other ❑ Delta Depth of Grout Seal Q-' Type of Grout aiNC Orr 'o 52J1pprox. Depth P-1 stern Surface Seal Installed by di- ❑ Type of Pump H.P. State"Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 l� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation wa serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ Total lengthIsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance-to nearest: Well Foundation Property Line c� DISPOSAL PONDS ❑ 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 Eoensed 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."Contractors 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 applicant nv4u,call T all r wired inspections. Complete drawing on reverse side. Signed K Title: PRM I D f-N Date: z yo 6�tw 'T. f{wt� x5p n/ FOR DEPARTMENT USE ONLY �� A Application Accepted by Date a Pit or Grout Inspection by Date '3' G Final Inspection by Date Additional Cortnnents: 71 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. INFO y +EH 13-24IREV.1/85) "W _JS. tCvc,