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APPLICATION FOR PERMIT SAN JOAQUWLOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 4&fi-f . . 7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . . {Complete in Triplicate} _ Application is heteby 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 a Local Health District. nd Regulations of the San Joaquin _ Job Address h Cit Y Lot'Si.- PM/ 7 , Owner's Name Address f 6Lyl Q!L Phone �C/ 1 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSDQ '. El Industrial Ll Open Bottom' -. ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter" Sealing Material (top 501 Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted 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/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation '177 Property Line LEACHING LINE W O' No. & Length of lines Total length/size ! FILTER BED ❑ Distance,to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size I Number SUMPS ❑ Distance to nearest: ' Well : Foundation _.Yfyoperty Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done-in-accordance with SanJoaquincounty ordinances, state laws, and t ( 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 p y persons subject to workman's compensa- tion laws of California." The applicant ust call for all required inspectio Complete drawing on reverse side. Signed X t Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date_ Area Pit or Grout Inspection Date Final Inspection by D Additional Comments: trW91 { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 — ❑ Trscy "835-6385' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O:'Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. + EHt3-24RREy.tie57313 ' EH 14-25 S/—101 Q