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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 install 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address b ` �`; City Lot'Size C/- PM Owner's Name ` Address Phone _ 1 Contractor Address r ! r License Na. Phone- TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ~! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPAAL.FL'D 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 pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack y ❑ Tracy f--'—Type of CasingSpecifications LJPublic ElOther . El Delta 1N Depth of Grout Seal ' Type of Grout ❑ Irrigation __4pprox. Deoh—'El Eastern Surface Seal Installed by ` Repair Work Done F` Type of Pump'— H.P. Staff Work Done Well Destruction! [IWeII Diameter Sealing Material (top 50'1 ' !l� Depth Filler Material (Below 501 9 f TYPE OF�SEPTIC WORK: NEW MSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence commercial Other Number of living units:_j__ Number of`,edrooms_ 3w. Character of soil to a depth of 3 feet: _ Water table depth R SEPTIC TANK ❑ Type/Mfg ��a—��}--- Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dis bsal + i p Distance to nearest: Well la Foundation y� Property Line LEACHING LINE No. & Length of lines Total length/size R FILTER BED ❑ Distance to nearest: Well /04? Foundation Property Line SEEPAGE PITS ❑ Depth ize # SUMP ' Distance to nearest: Well/ �� -`p.Foundation Property Line ._ DISPOSAL PONDS ❑ hereby certify that I have prepared thWappiication 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 orlicensed agent's signature certifies the following: "I certify that in theperformance°hof 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."' 3 r- ! It. - The applicant m s call for all required ' tions. CompI t dt ing.on�r side. s ' ;•. J Signed Titlet - Date: v �( +,FOR DEPARTMENT USE ONLY Application Accepted by ��1 W l�� 4. r 1 Date ` Lk—$ a �� Pit or Grout Inspection by Date Final Inspection by Qate ', Additional Comments: . - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca, 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Healfh,Permit/Services 1601 'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH KO RECEIVED BY DATE PERMIT`NO. + EH 13-24(REV.1/s5) EH 1420 - �5 •-