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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � � HL�� (Complete in Triplicate) �[� p�y+ N�A�- �S r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h�!'eir� rl��d�`'Tf1is application is t made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and ulations of the San Joaquin Local Health District. Job Address I.S G 13 �� DE1A7// � City t Obl Lot Size PM Owner's Name 1 #? rfr+r p l � Address X1 Phone Contractor Address Q U F k SLicense No.S O 14SO Phone% TYPE OF WELL/PUMP:. AEW.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 19 Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications y `r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout . I 1 Irrigation _.-Approx. Depth 11 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump .'C*U-J6- . H,P. State Work done V � Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (:) REPAIR/ADDITION 1 3 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.I 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/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal 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 I'] Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r. DISPOSAL PONDS ❑ F ' I hereby certifythat'I'have prprepared this--alication and that'the work will be done`in-accordance with San Joaquin county ordinances, state laws, and— pp 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 persons subject to workman's compensa- tion laws of California." 1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: F EPA T T USE ONLY Application Accepted by Date �r Area Pit or Grout Inspection by Date Final Inspection by L )late lar�i� Additional Comments: ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 Q 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 �AAMOUNT �lDUE AMOUNT REMITTED CASH CK RECEIVED BY DATE �PERMITNO. + EH114-28 3-24IREV EH .final 111/// �C.000 Od RR �