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' - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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, Job Address �`-� City + Lot Size PM Owner's Name " • � AddressPhone t� Contractors Address _= G"ice_nse No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom t ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic)Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by - Repair Work hone ❑, ,Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material l6olow -- TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I DESTRUCTION I 1 JNo septic system permitted if public sewer is available within 200 feet.) r,1 Installation will serve: Residence_ Commercial L-�6ther! _ _- .� .. _ a LE rL. Number of Irving units: Number of bedgo5 Character of soil to a depth-of-3-feet:..... Water table depth SEPTIC TANK ❑ Type/Mfg. : Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance tor nearest•:- -Well- - Foundation Property Line LEACHING LINE o'. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WellFoundation Property Line L!-C —� �F-da SEEPAGE PITS 10--Depth Size Igg _r Number SUMPS ❑ Distance to nearest: Well Foundation Property Line "� "� '�� - _P DISPOSAL PONDS ❑ 4- 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 0 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 certif a following: "I cartify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o aliforni . The applicant t ll for ll r luire nspe tin Go plate drawing on reverse side. r w Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted bjbyE� _ Date �� Area or Grout Inspection Date`d Final Inspection by 0!2Date Additional Comments: v.❑-Stk 466-6781 ❑ Lodi 369-3621-. =r -❑ Manteca 823.7104 -- -❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT-NO. INFO GASH ^� +-EH 13-24(NEV.r/H51 EH 1426 1J —I