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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA I988 Telephone (209) 466-6781 ' a PERMIT EXPIRES 1-YEAR FROM DATE. ISSUED (Complete in Triplicate) PERMiI i :--i-<vas 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. Job Address s,�__-� City / Lot Size PM Owner's Name td Address �1�� Phone 01 0a Contractor Address ,✓� License No. 6 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 15(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other F Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth I I Eastern 1 Surface Seal Installed by Repair Work Done Ik Type of Pump_4441__ M.P. &_/2C= State Work Done Well Destruction ❑ Well Diameter. Sealing Material (top 501 - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is �Q available within 200 feet.) Installation will serve: Residence_.- Commercial_ Other 0 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 Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L71 Distance to 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 n employ any person in such manner as to become subject to workman's compensation laws of California." Gini 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 II for all requed inspections. Complete drawing on reverse side. i Signed Title: Date; FOR D€PARTMENT USE ONLY Application Accepted by pa4e Area Pit or Grout Inspection by ate Final Inspection by Date 1G Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3627 ❑ Manteca a23-7104 ❑ 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 CK si CASH RECEIVED BY DATE PERMIT'NO. + EH 14-26 IFEv.1iH5) 136 O t��3a/6 g5?V-21,