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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 (Complete in Triplicate) 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_�/Sl 4i City Lot Size PM Owner's Nameih 'jreticr ,Address Phone /' Contractor � � Address License No/4 13 73PhoneJ1b'y ta.ZX__ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION f4 SYSTEM �REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �d�" SEWER LINES __,_tC�.-_1 ' DISPOSAL FLD. PROP. LINE FOUNDATION __..4,� AGRICULTURE WELL -,522!— OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing Domestic/Private %Gravel Pack ❑ Tracy Type of Casing Specifications >�, ('1 Public Ll Other Ll Delta Depth of Grout Seal Type of Grout�e.d u _ f I Irrigation _._Approx. Dep.!P l 1 Eastern Surf 9ce Seal installed by - Repair Work Done 14- Type of Pump H.P. lZ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) n tion will serve: Residence_ Commercial_ Other Number of Iry its: Number of bedrooms Character of soil to a dep feet: Water table depth - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE ❑ No. & Length of lines Tot th/size FILTER BED ❑ Distance to nearest: Well Foundation Propert SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS n 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, t shall employ persons subject to workman's compensa- tion laws of California." The applicant s call r all require Inspections- mplete drawing on reverse side. Signed X W Title: Date: F EPARTMT USE ONLY Application Accepted by rA Date ��s� K _/ Area Pit or Grout Inspection by Date Final Inspection by Date g { Additional Comments: Td ❑ Stk 466-6781 ❑ Lodi 369-3621 teca 823-7104 ❑ Tr y 835- Appiiicant - 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 RECEIVED BY DATE PERMIT'NO. INFO // CASH + EH 13-24(REV.i i H Sf 6/� q� Sl� EH N-26 VVV Vx