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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby (Complete in Triplicate) made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Re ulati Lad Health District. This application is g ons of the San Joaquin Job Address S C� L' Owner's Name � � «�� Lot Size PM Address t�CJ Phone Contractor's Name -TYPE'OF WELL/PUMp:�- — .._. License No. ' NEWWE �' -' WELL REPLACEMENT ❑ Phone PUMP INSTALLATION ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANKSYSTEM REPAIR ❑ OTHER ❑ SEWER LINES �� DISPOSAL FLD. FOUNDATION �� gGRlCULTURE WELL PROP. LINE INTENDED USE TYPE OF WELL PROBLEM AREA OTHER WELL PITS/SUMPS ❑ Industrial Bottom f CONSTRUCTION anon CATIONS ❑ Open ❑ Manteca Dia. of Well Excavation ❑ Domestic/private ' ❑ Gravel Pack—;—, • - Dia- of Well Casing ❑ Public C7 Tracy's 'Type of Casing" �-^ 11 Other El Delta Depth of Grout Seal Specifications ❑ Irrigation Repair Work Done ---Approx. Depth F1 Eastern of Grout Type of Pump Eastern Surface Seal Installed by s} ❑ ---Approx.Well Destruction �~ H.P. r� State Work Done --❑_ ameter�-----w ._.Sealing-Material-(top-50'}-- � Depth Well ,✓ '� ller Material TYPE OF SEPTIC WORK: LLATION NEW INSTAL, ❑ REPAI{RlAppl7'!ON Ll pESTAUCTION ❑ (No septic system permitted ifpublic !li Installation will se e: Residence available within 200 feet.) sewer is t. Commercial Other� r Number of living units: —/— Number of bedroo S -. Character of soil to a depth of 3 feet: y SEPTIC TANK ❑ Type/Mfg Water table depth d PKG.,TREATMENT.PLT. Clapacity�� No. Compartments r� f _ f V Distance to nearest: WellMethod of Disposal Foundation Property Line LEACHING LINEf 5e-INo. & Length of lines FILTER BEp ❑ Distance to nearest: WellTotal length/size d Foundation Property Line. SEEPAGE PITS E Depth SUMPSSize Number s 4-ri�istance to nearest, r f DISPOSAL PONDS Wel! Foundation ,/� r P or perry-Unel_ I hereby certify that l 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: "1 certify that in the 3 , 1 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Performance of the work for which this permit is issued, I shall not certifies the following: "I certify that in the performance of the work for which this permit,is issued, I shall employ tion Paws of California." p p y persons subject to workman's compensa- The applicant must f r all req ed ins pe ns. Complete drawing on reverse side. Signed Tine: Date: i FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Date Area (/ Date �J-_ Final Inspection by Additional Comments: / -- Date ❑ Stk 466781 ❑ Lodi 369-3621 ❑'Manteca 623-7104 Applicant- Return all copies to: Environmental Health'Permit/Services 1601 E,❑Hazelt n 6385 Tracy A e� P.O. Bax 2009 Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIY'NO. EH 13-24{REV, 1e/g31 }� eEH 14-28 `I S- d �