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f: i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 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 well/pump and the Rules and Regulations of the San Joaquin Local health District. E Job Address City Lot Size PM I Owner's Name __, /! �� 9F!6/�i� Address �� b �.! t-0C� &V.* Phon$ 1 Contractor Address License No. Phone 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 US�` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t0\ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public l ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ �1 Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction' El Well Diameter Sealing Material (top 50') Depth Filler Material lBelow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION LI DESTRUCTION I INo septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence ✓ Commercial_ Other j . Number of living units: I Number of bedrooms M Character of soil to a depth of 3 feet: Water table depth C{ SEPTIC TANK - ❑ Type/Mfg Capacity# No. Compartments PKG. TREATMENT PLT. El ;, ; Method of Disposal DistanceRo nearest: Well t Foundation f Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1-have prepared-this application and thal-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. f -,:- 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 must c for all requ'ed inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY —WIApplication Accepted by Dater= Area t Pit or Grout Inspection by Date Final Inspection by <71 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. +,£H 13-24{q EH 14-28 EV.i i A 5) 3 a v! �/