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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 3 PERMIT EXPIRES TYEAR 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 1 City bnde4-' Lot Size PM Owner's Name , Address . I. �OU L � ___ Phone'0'�1 Contract 4�—�dress t License No. 3774Phone ��:.� � 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 NPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS ❑ Industrial ❑ Op Bottom ❑ Manteca Dia. o Well Excavation Dia. of Well Casing LJ Domestic/Private ❑ Gravel oat ❑ Tracy Type of sing Specifications J I'1 Public F1 Other 17 Delta Depth of Gr t Seal Type of Grout I I irrigation _.Approx. D th i Eastern Surflacce Seal I talled by _ Repair Work Done ❑ Type of Pump H.P. 301 1✓- State Work Done !U4&eX- If Well Destruction ❑ Well Diameter Sealing Material {top 50'I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Numbe f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal l Distance to nearest: Well Foundation Property Line f j LEACHING LINE ❑ ,No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f r SEEPAGE PITS l I Depth Size Number SUMPS 0 Distance to nearest: Well-' Foundation Property Line DISPOSAL PONDS ❑ s I hereby certify that I have prepared this application and.tAat the work will be done in accordance with San Joaquin county ordinances, state laws':and 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 fallowing: "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 ap' " ust.call for a u'red inspections. Complete drawing on rev rse side. Signed Title: auoZ4 Date: f FOR DEPARTMENT USE ONLY Application Accepted by " Date '� D� Area Pit or Grout Inspection by Dat Final Inspection by .,, ,.,. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMWNO:;' INFO f� 1� CASH �L +..EH 13-24 14-284e[ptEv.fin51 EH 3S. Do �*t l fj-