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fi APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA e" Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ` 1967 (Complete in Triplicate) FniTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work � s (r�off �1 tion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules agd�t Hbr s5`CT tflean Joaquin Local Health District. Job Address V-3 v City Lot Size PM Owner's Name Degigm Address Phone Contractor_ Q /��5 � S Addressfy G License No. Phone TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION jj� 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 L1Industrial F] Open Bottom d Manteca Dia. of Well Excavation Dia. of Well Casing %Zomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public L1 Other C1 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._ I -. .w-- —State Work Donees -- Well Destruction 17) Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') UJ TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION [4 - DESTRUCTION 1',I-Mb septic system permitted if public sewer is available within. 200 feet.) f 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 ❑ ..Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ 4 Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING 6NE' ❑ No..&-Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 - SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: 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, an rules and regulations of the San Joaquin Local Health District. 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 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." The applicant t opr I require ctions. Complete drawing on rev rse �+ Signed X Title: J Date: p�y 7 FOR DEPARTMENT USE ONLY Application Accepted by Datel r Area Pit or Grout Inspection by Date Final Inspection by me_ Date ��$ Additional Comments: ❑ 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 95291 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24 IREV.t/x 51 3S yl bsn87-A IS3 EH 14-26