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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 Rules and Regulations of the San Joaquin Local-Health District. /f�j Job Address y7ol Cit Lot Size�� !' '�'PM d rfOwner's Name Address Phone // g ry I Contractor Address b W License N e 0 f'11one•J�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION�SYSTEM REPAIR ❑ OTHER ❑ S e 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �.. M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ i I Irrigation _Approx. Depth i Eastern �] Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. J�,!�� tate Work Done Well Destruction El Weil Diameter Sealing Material {top 50'1 ) t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlADDITION l I DESTRUCTION I 1 1No septic system permitted if public sewer is f :i n- - - V v available within 200 feet-) I Installation will serve: Residence_ Commercial_ Other r G j Number of,I-iving units: Number of bedrooms Character�ooil to a depth of 3 feet: t Water table.depth SEPTIC TANK 01 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size !FILTER BED f ❑ Distance to nearest: Well Foundation ..Property Line . I � ,SEEPAGE PITS s I I Depth Size _ Number y SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ # 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 s rules and regulations of the San Joaquin Local Healih District. 1 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." ;I The applicant ust tail f all required inspection Complete drawing on r verse sid Signed XTitle: ?> Date: JF FOR QDEPARTMENT USE ONLY i Application Accepted b,�� 1�t�w�' Date rJ /�;/) Area / Z Pit or Grout Inspection by Date Final Inspection by A G //O`7.4 Date Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED C/A�SjH// RECEIVED BY /DATE PERMIT'NO. + tR EH 14-2e EV.i/n 51 // �S V !V