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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTi ( 1 1601 E. HAZELTON AVE., STOCKTON, CA 1` � ! �3 Telephone (209) 466-6781 4: 41987 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) NyVROMENTAL HEALTH Application is herebymade to the San Joaquin Local Health District fora permit to construct and/or install th w {4 �$R,0CM application is q p ��3fidq�9 made in compliance with San Joaquin County Ordinance No.545 for sewage or No. 1862 for welll�/�,PuT and the Ru Regulations of the San Joaquin Local Health District. Y<tVY Ute' Cite Lot Size PM Job Address Y Phone Owner's Name Address I ContracE dressLicense No. Pane i TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I�/�•' SYSTEM REPAIR W� OTHER ❑ 0eVAC a.-� DISTANCE TO NEAREST: SEPTIC "TANK SEWER LINES % DISPOSAL FLO. PROP. LINE FOUNDATION y AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [3- o estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F Public ❑ Other �. P'Delta Depth of Grout Seal Type of Grout w ---. I 1 Irrigation Approx. Depth I. I Eastern Surface Seal Installed by - •Repair Work Done Type of Pump H.P- State Work Done i Destruction D Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR!.ADDITION-4,1 ;.DESTRUCTION i I (No septic system permitted if publics er is available within 200 feet.I Installation will serve: Residence-_ Commercial Other' Number of living units: Number of bedrooms r" Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg y Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well' Foundation Property Line SEEPAGE PITS T 1 Depth Size x Number SUMPS C1 Distance to nearest: Well Foundation T Property Line DISPOSAL PONDS ❑ f I hereby certify tha ve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and re tions of th an Joaquin Local Health District. Home ow r or licensed agen signature certifies the following: "I certify that in the.petformance of the work for which this permit is issued, I shall not employ a y person in such ma a as to bac a subjec workman's compensation laws of California Contractor's hiring or sub-contracting signature certifies he following: "I certif at in o an of a wor which this per is issued, I shall employ persons subject to workman's compensa- tion la of California." The ap icant m I req ample drawing on raver de ` Signed X Title: / te: 1 FOR DEPARTMENT USE ONLY Application Accepted,.byYCt Date Area Pit or Grout Inspection by Date' Final Inspection by 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 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH f r EH13-24(►iEV.1/n 5) r�0 EH 14-26