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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED r (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 r,. 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. vv Job Address ,�,c.�T� � ,�� -` City of Size Ze Pm Owner's Name Address Phone 49�� Contractor Address :Z L f y J J ,/! License.No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ �;'*` DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑� `4 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S`-,_DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom . ' Cl-Manteca' "'Dia:df Well Excavation ' Dia. of Well Casing rV ❑ Domestic/Privet; ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r,1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout W a ❑ Irrigation ti --Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Donek ❑ Type of Pump H.P. State Work Done Well Destruction a ❑ Well Diameter I Sealing Material (top 501 j Depth Filler Material fBelow 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION-LI"'REPAIR/ADDITION ❑ DESTRUCTION (No septic.system permitted if public sewer is available within 200 feet.l i ( 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 ❑!. Fyp,/Mfg - Capacity No. Compartments T PKG. TREATMENT PLT. ❑ s �> Method 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 1 ❑ Depth Size Number n { - 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. %. rr 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Califomia."Contractor's hiring r 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 torworkman's compensa- tion laws of California." The applicant ust call for a equir inspections. Complete drawing on r erse side. Signed �'`ice- Title: Date: ( FOR JINEIPARTIVIENT USE ONLY ` Application Accepted by Date Area Pit or Grout Inspection by Date Fina! Inspection by Date ` f �d ' tonal Comments: k 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appli nt- Return all copies to: Environmental Health Permit/Services-1601 E..Hazelton Ave., P.O:Box 2009, Stk.,-CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDry C K H RECEIVED BY DATE PERMIT'NO. INFO { [a �1 + EH 13-241REV.1/a 5) OIL) S4 d •" �`�+ s ��~9;l_51, EH 14-29 ✓✓✓