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�i 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 Rules and Regulations of the San Joaquin Local Health District. i Job Address ,fl�. ` City. Lot Siz PM Owner's Name _ (L✓frS� Address kUt� _ �"� � , Phone - Contractor's Name License No. G �- TYPE OF WELL/PUMP: NEW WELL Phon WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALL,�TIO SYSTEM REPAIR Eli OTHER❑ iCrTODIS NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLQ>. /�9 - PROP. LINE. FOUNDATION _- __ AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaDia.Iof Well Excavation t G� Dia. of Well Casing ,domestic/Private ravel Pack roc i ❑ Public � T y Type of Casing Specifications D.Other ❑ Delta Dept Irrigation h of Grout Seal � ' ❑ Irri Type of GroutA&1411 g —Approx. Depth ❑ Eastern 'Surface Seal Installed by I .,` (Z> Repair Work Done ❑ Type of Pump H P State Work Well Destruction 171 Well Diameter - �Sealirig Material (top 50'1 Q Depth 1 Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION' DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence Commercial--—Other - available within 200 feet.) r__ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK {.TWater table depth ❑ ype/Mfg PKG. TREATMENT PLT. Capacity No. Compartments 11 � " Method of Disposal Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ 'No. & Lengthlof lines ' Total length/size FILTER BED Q ,Distance to nearest7,,;,7 Well Foundation Property Line � SEEPAGE PITS ❑, Depth i Size i Number SUMPS9, -Distan a to nearest: Well I Foundation Property Line DISPOSAL PONDS IT M 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 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 inihe 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 Wt call for 11'r equire -i cions. mplete drawing on reverse side. 'Of I Signed Title; f Date: rQ_� F A R DEPARTMENT USE ONLY Application Accepted by Date 7 f Area Pit or Grout Inspection by � � T-Y ---Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 a. ❑ Tracy, 835-6385 Applicant- Return all copies to: Environmental xHealth Permit/Services 1661 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED J INFO CASH RECEIVED BY : F_., DATE PERMIT'NO.EH 13-24 IREV.101831 ��_ � l EH 1426 -.. .