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�. ;. APPLICATION FOR PERMIT ci/w +' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED -(Complete in Triplicate) li 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. City of Size /M .J�—[— Job Address y ) r� Owner's IN.- License Address LIL D Phone Contractddress NM&9 o� . Phone TYPE OF WELL/PUMP: NEW WELL.❑, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,Ll 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 'f ❑ Domestic/Private 0 Gravel LJ Tracy Type of Casing Specifications ~ I] Public f Other ❑ Delta Depth nf_Graut,Seat_ Type of Grout I I Irrigation 1, —,.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Belo 50') S �Y TYPE OF SEPTIC WORK: NEW INSTALL ION I1 REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is U available within 200 feet.) 'Installation will serve: Residence Commercial— Other t a Number of living units: Number of bedrooms Character of soil to a depth-of 3 feet: Water table depth " SEPTIC TANK 0 ' Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method juL.Disposal r Distance to nearest: 'Well ion Property Line V< LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ndation Property Line I SEEPAGE PITS I I Depth Size 211t umber UMPS 0 Distance to nearest: Well Foundation Property Line DIS SAL 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 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 Contractors 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, us ll to all req inspections. om ete drawing ort v rse side. 77 Signed X Title: Date: FOR DEPARTMENT_USE ONLY j Application Accepted by T — Date Area Pit or Grout Inspection by Date Final Inspection by t i ditional Comments: Stk 466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 0 Tracy 835-6365 ppplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. 1 INFO ("] � CASH ` + EH t3-24{REV.i/m sf n '!' o �--� \ 5 / IL EH 14-2e r