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APPLICATION FOR PERMIT a 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) 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 weii/pump and the Rules and Regulations of the San Joaquin Local Health District. Cityc�L1 Lot Size PM Job Address r ✓ VU I dy Address lak4 Phone Owner's Name, Gy G C L(, Addr �`� Sr�el Contract052025 License No.4AI Phone o�is�_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION JW SYSTEM REPAIR 3e' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS „ INTENDED USES" TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [71 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing WDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r l'1 Public 171Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation __.Approx, Depth I I Eastern Surface Seal Installed by G� - Repair Work Done )e Type of Pump H.P. State Work Done Well Destruction LlWell Diameter it Sealing Material (top 501 Depth � - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I INo 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/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Zin ' SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest:-_WellFoundation� 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 Dislrict. r 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." The applicant call for alyYequi d inspections. Complete drawing on reverse side. o no / / Signed X Title: ;� Date: 0 FOR PARTMENT USE ONLY 0 Application Accepted by Date I Pit or Grout Inspection by Date Final Inspection by✓ Date 3 Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Servicos 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO �7 CASH +.EH 53-24{REV.I/rt 51 F EH 14.26 'CJ F !