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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 y Local Health District. 2,77 �j f 1} 1 t ( a Job Address s J City Lot Size PM Owner's Narna6n k, ctk, Address Phone Contractor Address License No. Phone i TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑' SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a.• INTENDEDUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D. Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 11 Other 11 Delta Depth of Grout Seal Type of Grout _ I I Irrigation __._Approx, Depth l I Eastern Surface Seal Installed by \ �I Repair Work Done ❑ Type of Pump H.P. 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 I I DESTRUCTION {No septic system permitted it 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 � r 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 _.. f SEEPAGE PITS I Depth Size _ Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 f rules and regulations of the San Joaquin Local Health Di$trict. ' 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 applic st call for gy required inspections. Complete drawing on reverse side. Signed Title: G 7Z Date: i? FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by C 6 Data Final Inspection by Date j r Additional Comments: ❑ Silk .466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 - i FEE AMOUNT DUE AMOUNT REMITTED INFO ASH RECEIVED BY DATE PERMIT'NO. +.£H 73-24 IRE V.i i A 51 '�O/r;Q EH 14-26 �•7 r l