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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT t 1601 E. HAZE I ON AVE., STOCKTON, CA a Telephone {209} 466_6781 PERMIT EXPIRES I'YEAR FROM DATE ISSUED " * {Complete in Triplicate} Application is hereby made to the San Joaquin Local Health District fora �' made in compliance with San Joaquin County Ordinance No.549 for sewage or it t 1 on for t an pump and the Rales and Regulations permit to construct and/or install the work herein described- This application� Local Health District, e9 of the San Joaquin Job Address !PAl l Y City l7i��... Lot Size `l r PM Owner's Name T'hM, �/A �� _ Address t .= C5 s'u (JRd^J ; Phone Contractor `"""— ` — Address .�". _.- TYPE OF WELL/PUMP: r�C7. License Noc _ �� l NEW WELL ❑ WELL REPLACEMENT ❑ J�. .Phone PUMP INSTALLATION Ei DESTRUCTION ❑ 1 SYSTEM REPAIR ❑ DISTANCE,TO NEAREST: SEPTIC TANK OTHER ❑ —� SEWER LINES DISPOSAL FLD. l. FOUNDATION AGRICULTURE WELL i PROP. LINE INTENDED USE OTHER WELL PITS/SUMPS " 'TYPE OF WELL _: PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q industrial � O-Open Bottom ❑ Manteca ❑ DomesticlPrivate . F•, Dia. of Well Excavation ❑ Gravel Pack p.Trac r Dia- of Well Casin ❑ Public Gi Other y, Type of Casing ! ,s i S g ❑ Delta Depth of Grout Seal Specifications ❑ frrigatiori .D ---Approx. Depth _.O Eastern Surface Seal installed by . ( Type of Grout Repair Work Done . ❑ r # Type of Pump �4 H.P. Well Destruction ❑ Well Diameter State Work Done 1 i! De th ~~ Sealing Material (top 50') p Filler Material (Below 50') ^ TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted ' t d public sewer is Installation will serve; R sidence .� Commercial able m feet.) r avail with'� 200 t, Number of living units: b- Other�. ` g � Number of bedrooms i Y v Character of soil to a depth of 3 feet: SEPTIC TANK ❑ i �" Wait table depth Type/Mfg 1 a tri PKG. TREATMENT PLT. ❑1 CapaciRyk` U �lVo.'Compartments e r: ! Distance to nearest:, " Well A /! 7 �` Method of Dis os�l € Found on j i Property LineI. LEACHING,;LINE No. & Length o ( �'r--=� .�.. t f lines .. R FILTER BEDTdtal length/size (� v ❑ Distance to nearest: Well :FoundationT f 3 - �I-P.ropertq Line ,W01) ! ,' SEEPAGE PITS O Depth Size . . sh SUMPS Numbj. 'br�r � i ❑ Distance to nearest: - Well Foundation DISPOSAL,PONDS F1 Foundation Line `+ I hereby certify that f have prepared this application and that the work'ill be done in accordance with San Joaquin uin"!county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ an 4 p Y y�person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies ihe-following: "I certify that in the performance of the work for which this tion laws of California." permit is issued,I shall employ persons subject to workman's comperisa- The applicant must call for Ire 'red inspections. Complete- -drawing on reverse side. Signed ! - Title: 5- Date: FOR DEPARTMENT USE ONLY ApplicationiAccepted by � i Date 7„ 3 ( Area Pit or Grout Inspection by Date { Final Inspection by Date/ l Additional Comments: »� t 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 13 Manteca $23-7104 f ❑ Tracy;. 835-6385 '! Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED SCK INFO �__ CASH RECI VEDBY DATE t + EHi3241REV.s/85) �� C !� �� i• -- "" -y