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APPLICATION FOR PERMIT .; SAN JOAQUIN LOCAL HEALTH DISTRICT ° 1601 E. HAZE ON AVE., STOCKTON, CA Telephone (209) 466-6781 0C_ a �� 38 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) �� ; } , E ERVU-3' 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. , Job Address City Lot Size PM Owner's Name Address �� '�� Phone �1 T- Contractor AddressD av��c �.rt.rc�� __License No`�63 9 6 .Phone 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 b(DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout I 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done 'D4 Type of Pump H.P. State Work Done —� 6 Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth_�fJ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION LI DESTRUCTION f I (No septic system permitted if public sewer is Q available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ° Character of soil to a depth of 3 feet: ro """"" _ Water table depth SEPTIC TANK ❑ Type/Mfg CapacityY T - - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ': Well Foundation Property.Line t LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED — """ ❑—Distance'to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth' Size : Number SUMPS ❑ Distance to nearest: Well A- Foundation Property Line DISPOSAL PONDS ❑ a •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 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 must call for all(equir d inspections. Complete drawing o reverse side. Signed X _ Title: Date: /0 ^02� FOR DEPARTMENT USE ONLY Application Accepted by Date ` � Area 6 Pit or Grout inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 - ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. INFO ♦.EH 1 -24IitEV.1/e51 �'S, EH 144-28