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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r . 1601 E. HAZELION AVE., STOCKTON, CA { Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) e�,,r:;`• Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiF dps 61i ed:,�This`appl cation is made in compliance with San Joaquin County Ordinance s o.549 for sewage or No. 1862 for well/pump and the Rules and Regulafions'of the=San Joaquin Local Health District. 5-36 `J F a. ZY 3p*( r � � City Lot Size PM Job Address � /-7 Q !� i1(9 7 �JI1-+cam Phone Owner's Name - Address Contractor Address PD lk� !j: �c (License No. - Q ' Phon 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 PITSISUMPS. { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 l Public n Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Dept. 11 Eastern Surface Seal Installed by - Repair Work Done Type of Pump H,P. 0' . State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 , n Depth Filler Material (Below 501 lla TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) c Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- 1-1Method 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 I I DepthSize 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 Di%trict. 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 E certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subiact to workman's compensa- tion laws of California." The applicant for all re red inspections. Complete drawing onrverse side. z Signed Title:-/.saw Date:. 'Z� - FOR DEPARTMENT USE ONLY L0� i Application Accepted by Date r Area Pit or Grout Inspection by Date Final inspection by �2 Date Additional Comments: f ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 } Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. fr INFO QQQ ,[, *-EH 13-24 tREV.1/851 U I `� EH 14-29