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APPLICATIO FOR PERMIT �n f ,,,t� b SAN JOAQUIN CAL HEALTH DISTRICT I�'t 1601 E. HAZE T 0 VE., STOCKTON, CA ApvS _ Telephone (209) 466-6781 C&k }a �"`�� PERMIT EXPIRES TYEAR FROM DATE ISSUED i (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. P M City Lot Size Job Address i , Address IV Phone V Owner's Name rr n Contractor �ess L�w�� "L'icehse No. � /A/9 Phon *� � TYPE OF WELL PUMP-. NEW WELL PUMP-. 71 REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ : SYSTEM REPAIR IK OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._— PROP. LINE R FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t 1W 'r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial fl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout —. Ifelrrigation --Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State aWork Done dr R Well Destruction ❑ Well Diameter Sealing Material (top 50`1 y \ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION ( I DESTRUCTION l I (No septic system perm ted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size — Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSI4L7PONDS� ❑' P I hereby certify that I have prepared this application and that the work wilt 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 fo all required inspections. Complete drawing on reverse side. '7� Signed X Title: Date: `6 F R EPARTMENT USE 041Y Application ccepted by Date �� Area Pit or Grout Inspection by Date Final Inspection by 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 CK 11 PEE AMOUNT DUE AMOUNT REMITTED CASH IFEE RECEIVED BY DATE PERMIT'NO. NFO 7 a. ~Z2t EH 13-24(REV.I/A5) CAOT EH 14-2e