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} APPLICATION FOR PERMIT SAN JOAQUIN�LOCAL.HEALTH DISTRICT a 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's ' tr e- : • �... s. s '` .. . Job Address 9 tet ' fi y Citya" w .Lot Size PM Owner's Name r Address r_ A Phone Contractor ' _Address & License No PhoneR -J-8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'R Domestic/Private i❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by W Repair Work Done LJ Type of Pump .A-r cam►-- H.P. State Work Done K-44 Well Destruction ❑ Well-Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.] Installati' rve: Residence— Commercial— Other Number of living units: bar of bedrooms Character of soil to a depth of 3 feet:. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El of Disposal 4, Distance to nearest: Well Foundation Property Line 777tk !O LEACHING LINE !•O No &I Length of.lines Total length size FILTER BED ❑ , Distance to artist:_ We11 - 'Foundation Property Line' " SEEPAGE PITS ❑- Depth �'"S s Number Y I SUMPS ❑ Distance to nearest: Well - .� Foundation -Property Line DISPOSAL PONDS ❑ 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:'Ircertify 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."Contractors 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 all for all required inspections. Complete drawing on reverse side. t n Signed 1 D Title: i�-�- Date: to`"/;- — 07 FOR DEP TMENT USE ONLY Application Accepted by Date D Z� Area Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95201 FEE AMOUNT DUEL AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO , EH13-24(REV.sie51 �S�QQ8_3 r EH 14-28