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s: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA N©uw 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 install the work herein de rbc ibed. 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. 'r i Job Address 0 City �1 r"` Lot Size PM 4 Owner's Name �� -1 Address Phone / Contractor �� AddressLiV cense W Phone(A�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public f 7 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK:- NEW INSTALLATION 1�1 REPAIRIADDITION l 1 DESTRUCTIO 1 o septic system permitted if�P-bficewer is _ available within 200 feet.) Installation will serve: Residence-�._ Commercial,- Other w Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit�~��-� No. Compartments p Y 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: VVelf .,Foundation- . Property Line SEEPAGE PITS I I Depth Size Number SUMPS EI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ - Property Line 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 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 perso ch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follo in certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion taws of Cali orni The applicant m st I r inspections. Complete drawing on r e side. Signed X Title: --� _ Date: �y F DEPAR I�IENT USE ONLY p Application Accepted by „��Y� Date1 O Area Pit or Grout Inspection by Date �FinalInspection byDateAdditional Comments:❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Man ca 823-7104 acy 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 C K RECEIVED BY DATE PERMIT-NO. r EH U-24 1REV,1/R 51 C 3 ' �J r�/-O�j, — 7 ` EH t4-18 �J J v 5W 'l