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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 46B-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 Rules and Regulatiof the San Joaq Local Health District. ons uin t f Job Address .01 Ilk City Lot Size15-0)OZO PM Owner's Name Address " Phone Contractor _ —Address TYPE OF WEI_I_/PUMP: �" — -- - icense No. Phone_ s NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANKOTHER LI SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL '� """ `"""""'---��-�---.•— -- _ OTHER WELL PITS/SUMPS " INTENDED USE z, ,.w.T - - TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPEClF1CATIOIVS'!"""°`"a" ❑ Industrial � -� :El Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private A ❑ Gravel Pack ❑ Trac 1-1 Public Y Type of Casing Specifications ] ,, i CI Other n Delta I 1 Irrigation ' f 'f Approx. Depth I 1 Eastern Depth of Grout Seal V Type of Grout. H.Pi Repair Work Dane ❑ Type of Pump Surface Seal Installed by , Well Destruction ❑ Well Diameter ---�----,>� State Work Done Depth Sealing Material-(top'50')-- Filler Material 18elow 50'1 ice] TYPE OF SEPTIC WORK; NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION �` septic system permitted if public sewer is Installation will serve: Residence L�Commercial available within 200 feet.) -.— `_Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity— No. Compartments Distance to nearest: Well Method of Disposal Foundation Property Line LEACHING LINE ; ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: d Well Total length/size Fot `. s Foundation Property Line €9 SEEPAGE PITS I 1 Depthli Size Number SUMPS D Distance to nearest: Well DISPOSAL PONDS Foundation 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 Di§trict. 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 certifythat in the performance of the work for which this permit is issued, i shall employ tion laws of California." ❑ y persons subject to workman's compensa- tion ' The applicant St all or it r uire inspec ns. plate drawing on reverse Sid Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by T I� � Date 1 Area Pit or Grout Inspection by bate Final Inspection by Date �� Additional Comments:2 �a c� ❑"Stk 466-6781 D Lodi 369-3621 ❑ anteca 823-7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelton Tracy 835-6385 3Ave., P O. Box 2009, Stk., CA 955201 FEE AMOUNT DUE CK t�llt - INFO AMOUNT REMITTED i RECEIVED BY l� CASH DATE PERMIT NO. +.EH 13-24/REV. EH 14-28 � v