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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZEL T ON AVE., STOCKTON, CAS Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED7. ' (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- {' LlC4 City Lot Size` P Job Address - P Owner's Name _ Address •3 4 � ne" 23 ! Contractor Address Q License No. Phone W TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION D SYSTEM REPAIR 1-1OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK -C2.W _+.- SEWER LINES DISPOSAL FLD.1!2W PROP. LINE i FOUNDATION AGRICULTURE WELL L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t� r El Industrial El Open Bottom ED Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ T Domestic/Private Gravel Pack Tracy YP e of Casing Specifications 7i G `( ki Public ❑ Other ❑ Delta Depth of Grout Seal T o Groin LlIrrigation __-Approx. Depth L] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 _( Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic systithin m emitted if public sewer is w - Installation will serve: Residence, Commercial Other J _ = Number of,Iiving units: .;Number of bedrooms' Water table depth Character of soil to a depth of 3 feet: ( Capacity No. Compartments SEPTIC TANK C] Type/Mfg PKG. TREATMENT PLT- El 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to 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 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 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- I tion laws of Cnia." 4 The app' ust call for all r uir nspections. C plete drawing ve a s' 1 Signed Title: Date: a FOR DEPA MENT USE ONLY Application Accepted by LN Date Area Dated Final Inspection by s Date Pit or Grout Inspection by z t q- 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 CASH RECEIVED BY DATE. PERMIT NO. IIVFO G� , + EH 13-241REV.1/65} EH 14-26