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APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4�M .i 1601 E. HAZEL T ON AVE-, STOCKTON, CA Telephone (209) 456-6781 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. Job Address City Lot Size ra' 1 a-�,`-R�PM 9y S Owner's Name Address -!T4900 Phone Contractor Address License No, 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC( S V 1 ! ❑ Industrial I ❑ Open Bottom Cl Manteca Dia. ofavation Dia. of Well Casing i13- Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications 3 �� f`l Public ❑ Other elta Depth of Grout Seal Type of Grout _ O a I I Irrigation Depth I I Eastern Surface Seal Installed by ,. Repair Work Done ype of Pump H.P. State Work-Done_ 1 Well Des on ❑ Well Diameter Sealing Material (top 501 N Depth Filler Material (Below 501 + TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r 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 I 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 11 Depth Size Number 1' SUMPS ❑ Distance to nearest: . Well Foundation Property Line f ry 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 ' rules and regulations of the San Joaquin Local Health District. t 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 i 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." ant must call for all required inspections. Complete drawing on reverse side. Signed � Title: -- Date: _��.....�� FOR DEPARTMENT USE ONLYfr- Application Accepted by Date � r / Area t Pit or Grout Inspection b Data Final Inspection by Date " S Additional Comments; Y"' ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 822N7104 ❑ Tracy 835-6385 + Applicant - Return all copies to: nvironmental Health Permit/Serv'ees 1Q011 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 CeG IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. -7/3 0), I + EH 1 -24(REV.1/H 5) EH 4