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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. ZlfsJVT /V &E W. L W.) Job Address t �C A1#Xr.V 01VCity i.EIJ,E/ Lot Sizees PM Owner's Name 9- z::) . Address Phone ^ � LtJlJ�ie. Contractor N010 Address i TYPE OF WELL/PUMP: NEW WELL ❑ w --L�cense_I�4o Phone — WELL REPLACEMENT.❑ DESTRUCTION• ❑ PUMP INSTALLATION JD&PLAIC44#0AYSTEM REPAIR ❑ , I OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES L' DISPOSAt:FLD. -PROP. LINE FOUNDATION — AGRICULTURE WELL —"—OTHER WELL "" PITS/SUMPS' INTENDED USE TYPE OF WELL PROBLEWAREA CONSTRUCTION SPECIFICATIONS. ❑ Ind}�st�ial - — —` _E1 Open Bottom CI Manteca` =��Dia..-of Well Excavation:---- `" 1-1 Domestic/Private 1-1 Gravel 4ck. ❑ Tracy T Dia. of Well Casing Type of Casing Specifications ; ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal ' ❑ Irrigation _.._A Type of Grout _ �•�pprox. Depth ❑ Eastern Srd ace Seal Installed by Repair Work Done ❑ TType of Pump H.P. .q .. -- State Work Done �l1L 1.. �E�rt✓7�l/,E` Well Destruction C7 Well Diameter Sealing Material (top 50') f �.: � Depth Filler Material (Below 50') t ____ y,�•<„T TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system 1 ~! r^ permitted if"pu public sewer is Installation wflf serve: Residence_ Commercial Other available within 200 feet.) f Number of living units: Number of bedrooms Character.of soil To a depth of 3 feet: ` Water table depth SEPTIC TANK EJType/Mfg Ca ci PKG. TREATMENT PLT. E1Pa tY No. Compartments 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 t I ^ SEEPAGE PITS ❑ Depth SizeNumber i SUMPS ❑ Distance to nearest: Well Foundation i DISPOSAL PONDS Li Property Line 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, I shall employ persons subject to wo'rkman's compensa- tion laws of California.” The applicant u t call rail ) pections. Complete drawing on reverse-oside. �7�- 1�. Signed Title: —��—� L�� Date: € �� FOR DEPARTMENT USE ONLY Application Accepted y > �, :: ,l Date". " Are I Pit or Grout Inspecti y Date Final Ins " pection by Date 3 rY Additional Comments: ❑ Stk 4&6-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009;Stk.,GA;.55201. FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE — PEERNO.EH 1}24/REV.i/e 57 � �` �0 1�� I �EH 1428 ��