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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES-1 YEAR FROM DATE ISSUED „ (Complete 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 cif the San Joaquin Local Health District. Job Address Cit f Lot Size PM Owner's Name Phone Y Contract J 7 ti2iddress 7k7 License No.��Z�l� Phone �J TYPE OF W UMP: sNEW WELL L1WELL REPLACEMENT Ll DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION �GRI000TVRE.WELL_ ..OT.HER_WELL _P-ITS/.SUMP-S--_ INTENDED USE TYPE OF WELL _ .� PROBLEM AREA--%CONSTRUCTION-SPECIFICATIONS _ { ❑ Industrial ❑ Open Bottom s ❑ Manteca " Dia. of Well Excavation— � Dia- of Well Casing F ❑ Domestic/Private ❑ Gravel Pack - ti❑ Tracy Type-of-Casing — Specifications ❑ Public -kR-Other ;M-Delta Depth of Grout Seal Type of Grout ❑ Irrigation ""Approxi Depth Ll Eastern .fb,.r' Surface Seal Installed by I Repair Work Done ❑ Typ of'Pump---,-- H:P. - ' State Work Done a t Well Destruction "❑ Well Diameter Sealing Material (top 50')x' y } Depth ' e Material(Below 501 u 1 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAI /ADDITION ❑ DESTRUCTION,❑ (No septic system permitted if public sewevis O available within 200 feet.) ; Installation will serve: Residence Y ommercia4' Other tv Number of living units:___ Number of b Brooms 1 y Character of.soil to a depth of 3 feet:� ! Water table depth �@ i SEPTIC TANK ❑ Type/Mfg 'S c 'Capacity No,_C.ompartrneuts - PKG. TREATMENT PLT. ❑ # r Method of Disposal.' Dis nee to nearest: Well = Foundation Property Line % y � ¢ LEACHING LINE No- & Length of lin B T"-Total length/size11615�111_ X-2) k FILTER BED ❑ Distance to nearest: WeII��Foundation Property Line n GE PITS w ❑❑Depth �� Size�// Number 1-1 S < . P -Distance to nearest: Well19-�a—FoundationProperty p �Pro a Line i �.,;._.DISEO.SAL,�P_ONDS�.p - J 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."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." i The applicant m�-Ycall for all req uir inspections. Complete drawing on reverse side. ; Signed X Title: Date: FOR DEPAR4AENT USE ONLY Application Accepted by Date7- Area I x Pit or Gr t Inspection by to //' nal Inspection by ate . Additinal Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;Stk., CA 95201 r FEE. _ AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT ND. ' {NFO CASH + EH 13-24(REV.ti/K 5l �Q`� - !.r I Cit 14n EH 14-28 6 �O