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APPLICATION FOR PERMIT Al SAN JOAO.UIN:LOCAL HEALTH DISTRICT 4Zil�� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 7 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 appficatiorl:��LTYI . made in compliance with San Joaquin County Ordinance No.549 for sewage or No1862 for well/pump and the Rules and Regulations of,"tS�n"�Koa�u Local Health District. ¢ t` I.i �}, Gci, -acv' s .. Job Address �I� ,,. �.c�I� :City Lot Size PM Owner's Name Address Phone Contractor ( Address (� J- '�� License No!4D Z. 23 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 PiTS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Spec cations Cl Public � ❑ Other ❑ Delta Depth of.Grout Seal Type of Grout EJ Irrigation _�4pprox1Depth-p-❑-Eastern-- Surface Seal Installed-by— Repair nstalled-by Repair Work Done Type of Pump ,�. H.P, /L I State Work Done 5L-ae �bWeil Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION- ❑ DESTRUCTION ❑ (fJo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence{ Commercial_ other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet:I- i -table-lepra SEPTIC TANK ❑ Type/Mfg Capacity t No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance linearest: WellFoundation a Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � f SEEPAGE PITS ❑ Depth I Size Number , SUMPS ❑ 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 coup Joaquin rules and regulations of the San Joaquinlocal Health District. q county ord ances, state laws, and Home owner or licensed agent's signatute 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-dontracting 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 st c 11 for all re uired ins ctions. Complete drawing on reverse side. Signed le: Date: FOR DEPARTMENT USE ONLY' Application Accepted by I Date_ � � Area Pit or Grout Inspection by I Date Final Inspection by Date .I I - Additional Comments: ❑ Stk 466-6781 ❑Lodi 369-3621 Q Manteca 623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK 40 INFO CASH RECEIVED BY DATE PERMIT NO. + EHt3-24SFiEV,tis51 EH 1428 i w,.