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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES 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 Ryles and Regulations of the San Joaquin Local Health District. �i �;. R CJ j y A StLot Size PM Job Address ra• qs. . ten, u Owner's Name Address.922! Phone g 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 .a� FOUNDATION: _AGRICULTURE WELL, OTHER,WEI_L: _PITS/SUMPS —_.� ` INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial LJ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing W-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing___________i__ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout J] Irrigation ---Approx. Depth I ❑1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump„�d�, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is N available within 200 feet.) 1 T Installation will serve:--Residence— Comm ercial._--Other- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: `Water table depth SEPTIC TANK ❑ Type/Mfg- =- '-' ' -- -' Capacity' - 4No. Compartments PKG. TREATMENT PLT:❑ Method of Disposal d Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well lFoundation Property Line SEEPAGE PITS ❑ Depth Size ' ' Number L/ SUMPS ❑ Distance to nearest:' ,.l.-well'° /,Foundation _ Property Line C1 DISPOSAL PONDS �-❑- : =:� �t-a--�• : — rte„=� _ .. l 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 r" 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 workman's compensa- tion laws of California." The applicant r9ustY ll far required inspections. Complete drawing on reverse side. Signed : . Title:—�'' I�t/. r .' Date: T- .. F R DEPARTMENT USE ONLY p Application Accepted y Date c Area Qa. Pit or Grout Inspection by Date , Final Inspectio ;,,':—:Final by OOOF 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.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT`N0. INFO + EH 13-24(REV.IIasl �r0 r ��- 1� 5/T / Y EH 14-26