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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made toi 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. Job Address City Lot Size PM Owner's Name Address y Phon j 4 Contractor Address License No.d Phone TYPE OF WELL/PU I�I NEW WELL El WELL REPLACEMENT CI DESTRUCTION ❑ PLUMP INSTALLATION ❑ SYSTEM REPAIR DISTANCE TO NEAREST: SEPTIC TANK OTHER CI SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEDUSEm ._TYP-E_OF W..ELL„_._-P-ROSLEM.AREA-.CONSTRUCTION CATIONSSPECIFI _ ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation � �-�. ❑ Domestic/Private Dia. of Well Casing _ ❑ Gravel Pack L] TracyTypo of Casing r 11 Public ❑ Other � Specifications Ll Delta Depth of Grout Seal_ Type of Grout I I'Irrigation --�,q pprox. Depth ` "I f Eastern Surface Seal Installed by Repair.Work Done ) Typ' of Pump H p F-State Work Done I Well Destruction ❑ w Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I t]ESTw RUCTION i I (No septic system permitted if public seer is Installation will serve: Reside J1 Residence— Commercial.._ Other available within 200 feet.) r t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: + SEPTIC TANK Water table depth ❑ J,ype/IUlfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ J Method of Disposal I. _ D 11 istance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines ! �ati + Total length/size FILTER BED p Distance to nearest: Wel! Foundon " �1" �f I Property Line SEEPAGE PITS I'] ' Depth Size d SUMPS '� Number _ _---..L'l=r0iistance-to"nearest:--==..Weil=- _Foundation _Pro e . i'PONDS n epISPOSAL I _ hereby certify that l have prepared this apptication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the,San'Joaqu`in Local Health District. Home owner or licensed agent's.. ignature certifies the following: "!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 thai'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."_ I� - S _ The applicant st, I for all re" ired.in ctions. Co ete drawing on reverse side. ' Signed'X > '' _ - Title: Date: r I FOR DEPARTMENT USE ONLY E Application Accepted by Date 0,Z Area Pit r Grout In pection by C Date g Date final Inspection by i it Additional Comments: 1,. ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ Mantecai�r'lracy ;835 6385 ' Applicant - Return all copies to:Environmental Health Permit/Services 1601 E. Iiazelian Ave., P.O. Box 2009, Stk., CA 95201 r •. Y -- �°� FEE:• .._.__� '� ...�..,._----.- ...-,.. ...,,.�.«--;--- -----..�-,..-.,-.------...- -- -,.- �..,..,. -----•-----,-. ;\� ' INFO -AMOUNT AMOUNT REMITTEDK RECEIVED BY CA9H DATE PERMIT'NO. r.EH 13-24{REV;rin�sr . t. ._ EH 14.29 �� •� L�'7 .��. �� 9ta '70 —1 s7