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APPLICATION FOR PERMIT C� =SAN JOAQU14LOCAL:HEALTH DISTRICT " G 1601 E. HAZELTON jAVE., STOCKTON, CA Telephone (209) 466.67$1 PERMIT EXPIRES-1 YEAR FROM DATE ISSUED` ,,tlsly �; (Complete in Triplicate): •: _ Application is hereby made to the San Joaquin Local Health District for a permit to'Co'ns'truct and/or install t made in compliance with San Joaquin County x h Local Health District. ' ? t g9ID2 4 tY Ordinance No.549 for sewage or No. 1$62 for well/pump and the Ryles and Regulations of the San Joaquin he work herein described. This application is Job Address Cita Lot Size Owner's Name PM r ftddress Contractor -'r' ---- _-_ Phbn TYPE OF WELL/PUMP. Address p NEW WELL,.❑ WELL REPLACEMENT phone VBG PUMP INSTALLATION;❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK i-Ii SYSTEM REPAIR ❑ SEWER.LINES OTHER ❑ I ..: �- DISPOSAL FLD, i ION �� AGRICULTURE WELL OT ^ ' INTENDED USE TYPE OF WELL PITS/SUMPS ❑ Industrial PROBLEM AREA-1 ON SPECIFICATIONS 1i ❑ Open Bottom ❑M f ❑ Domestic/Private f" -`-�-- Dia. of Well Excavation E L! Gravel Pack�" C1 Trac'y'�"'-'- �"^^-- Dia. of Well Casing ❑ Public ❑ t Y Type of Casing 4 ❑ Irrigation 3 ( ❑ Delta Depth of Grout Seal cifications ---Approx. Depth ❑ Eastern -------- Pe of Gro } t Repair Wor he SurlaceiSeal Installed by ❑# TYPeofPumpH.P. Well D struction ❑4 Well Diameter _ State Work Done { i DepthSealing Material (Jop 50') TY �`r`'�,Filler Material (Below 50') , t PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR'/ADDITION ❑ DESTRUCTION ( (No septic system permitted if public sewer is Installation will server Residence Commercial available within 200 feet.) Number of livingunits: r Other Number of bedrooms ? Character of soil to a depth of.3 feet ( / d SEPTIC TANK 1 ❑ Type/Mfg __ _- Water table depth PKG. TREATMENT PLT. ❑ ! Capacity - No. Compartman s } Distance to nearest: Well Method of Disposal # Foundation Property Line LEACHING LINE 1 ❑ No. & Lei ngth of lines .y. Total length/size i FILTER BED ❑ Distance-to nearest : Well Foundation Property Line i SEEPAGE PITS ❑ Depth f j SUMPS Size Number ❑ Distance}to nearest: Well Foundation DISPOSAL PONDS � ❑ Property Line 1 hereby certify that I have prepared this application and that the work will be do r ; f rules and regulations ofthe San Joaquin Local Health District. done in accordance with San Joaquin county ordinances, state laws, and a. Home owner or licensed agent's signature certifies the following ) certify that.in the_performance_of the_work_for which..this-permit-is-issued,Lshail not employ any person in such manner as to become subject to workman's compensation laws of California."Cont►actor'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 for all required inspect' ns. Complete drawing re arse side. � Signed Title: Date: FUSE ONLY Application Accepted by Date Area Pit or Grout Inspection by - DateOR DEPARTMENT- Final Inspection by Additional Comments: 6 1 Dater ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environments! Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED RECEIVEb BY CASH DATE.. PERMIT`NO. EH 13-25(REV.1/.e 51 - EH 7426 ��