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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'l YEAR FROM-DATE ISSUED iComplete in Triplicate} r ; 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. " 5 i Job Address` City_i&d Lot Size ,' PM Owner's Name !�` .�/ '7'�+Address Phone y ! Contractor "1",-4ss M i ense No. Phone Il [/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11PUMP INSTALLATION ❑ SYSTEM REPAIR 113 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA;EL FLD. PROP. LINE FOUNDATION =AGRICULTURE WELL OTHER WE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONSBfietFTcATIdNS ❑ Industrial ❑ Open'Bottom ❑ Manteca Dia. ofW cavation Dia. of Well Casing Y ❑ Domestic/Private D Gravel Pack ❑ Tracy of.Casing Specifications ❑ Public ❑ Other. ❑ �st�6m �r�, Depth of Grout Seal Type of Grout ' ❑ Irrigation _Apprax. Depth 'Surface Seal Installed by Repair Work pone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil . ter Sealing Material {top 50';1.' epth Filler Material (Below 50'1 TYPE OF SE ORK: NEW INSTALLATION L7 REPAIR/ADDITION ❑ DESTRUC �N-INo�;ec system permitted•if public sewer is within 200 feet.! Y Installation,.will serve: Residence_ Commercial_ Other ` Number of living units: Number of bedrooms Character of soil to a-depth of 3 feet: I Water table depth T SEPTIC TANK ElTypQ/Mfg Capacity—'s No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well -r Foundation 7Property Line y4 LEACHING LINE Q No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundations Property Line i SEEPAGE PITS "� ❑ ,.Depth Size k T :-^ Number SUMPS _ b1 s .,E. Distance Jto 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 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 mjist CEVorla req :a.. in ctions. Compi Compdrawing on a rse side. t Signed Title: Oate� O J RTM T USE ONLY Application Accepted by Date Area C/ >;` — Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: S ❑ Stk 466-6781 ❑ Lodi 369-3112511 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT�'NO. + EH14.26(REV.ti551 � ��9- 7—Slb�. ,. ..