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A <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />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 <br />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 <br />Local Health District. <br />Owner's NameA 71CIVAF51 N AAddress`s 477r C11—A Phone Za.)q <br />e c- , PE -1 LL4 4 oil (Im��CA <br />Contractor I �' Address �'' �� ('"" '4r [� License No. _ Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ O <br />711* fZ- <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT j , <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P OP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />('1 Public ❑ Other L1 Delta Depth of Grout Seal Type of Grout <br />I I Irrigation _- Approx. Depth 1 I Eastern Surface Seal Installed by _ <br />Repair Work Done ❑ Type of Pump H. P. State Work Done <br />Well Destruction ❑ Well Diameter Sealing Material (top 50') <br />Depth Filler Material (Below 501) <br />TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial _ Other <br />Number of living units: Number of bedrooms I <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. ❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE ❑ No. & Length of lines Total length/size <br />FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS ' I I Depth Size_Number <br />SUMPS L1 Distance to nearest: Well _ Foundation Property Line <br />DISPOSAL PONDS ❑ + <br />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 <br />rules and regulations of the San Joaquin Local Health Diktrict. , <br />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 <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />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- <br />tion laws of California." <br />The applicamust I all required inspections. Complete drawing on reverse side. <br />Signed X ✓ti-«d-B—�� Title: _�(i�Q� Date: 'Z�Zlm <br />Application Accepted by <br />Pit or Grout Inspection by <br />Additional Comments: <br />F R DEPARTMENT USE ONLY <br />AAA Date %2 z <br />Dat© Final Inspection by a Date .1 <br />---------------- <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />♦ EH 13-24 1REV. +i a 5) <br />EH 1428 <br />INFO ,AMOUNTDUEAMOUNT <br />REMITTED <br />CK <br />RECEIVED BY <br />DATE <br />PERMIT*NO. <br />ly­) <br />ro <br />�P <br />U, <br />