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APPLICATION FOR PERMITp� ± SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TION 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address a Izoo . e Ac, City of Size PM Q plepsa�-F��tI Owner's Name Address 3 7 Phone 7 + ContractorF ef �v—_12,s Address Q License NoZ_!�73 Phone TYPE OF WELL/PUMP:' NEW WELL © WELCREPLACEMENT .❑ DESTRUCTION i 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 '' 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificationsl.f''�^^ FI Public [- Other 1 ❑ Delta Depth of Grout Seal Type of Grout;L�� I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 21ate Work Done Well Destruction !� Well Diameter Sealing Material {top 50') Depth 4elf(ylaterial (Below 50'1 0 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) tnstaltation erve: Residence Commercial_ Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Comppartme to sem` PKG. TREATMENT PLT. ❑ ,- ' . ��T ; Method of Disposal"' Distance to nearest: :, Well Foundation Property Line LEACHING LINE No.—& Length of linesTotal length/size FILTER BED ❑ Distance to nearest: x Well Foundation Property Line r SEEPAGE PITS I Ij Depth s Size _ --,Number--- _ y� SUMPS ILfl,. Distance nearest: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 regulationso he San Joaquin Local Health District Home owner or Ii sed ag s Sigriature certifies the'616wing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any per n in such ma ner alto become subject 'workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f owin : "I cert' that in the rformanc t e work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of aGfor a." The applic nt all or all re ire I mplete drawing Si a � — Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date,4— Area Pit or Grout Inspection by Date 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 PERMIT•NO. INFO CASH +.EH13-24 IREV.1/H 51 - `r r Ll EH 14.26 "1