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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal[the work herein described. This application 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 City tiJ► `'r`a_ Lot Size PM . ✓rI �[ Owner's Name 4,5 l+ , S � 0('�ddress Phone tU�� r\ Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'df Well ExcavationDia.— of Well Casing �1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications iI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ ! I Irrigation —._Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P._ .:State'Work Done _ Well Destruction Ellin Well Diameter —- . Bag Material [top 50')x.. � P Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION Ns/No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other Pa4ilable within 200 feet.) 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. ❑ 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 I I Depth Size `_ Number ' SUMPS Ll Distance to nearest: Well Foundation Property Lino 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, and iI 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, I 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 3wT call f all7,red in coons. Complete drawing on reverse side. Signed X Title: ✓� Date: _X `�3:_� FOR DEPARTMENT USE ONLY Application Accepted by Date "a3 - t Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 INFO CASH RECEIVED BY DATE PERMIT'NO. +,EH 13-24(REV,1 i n 51 2� EH 14-2e