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I APPLICATION FOR PE4MIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 11 ,JA 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. 1.862 for well/pump and the,Rules and Regulations of the San Joaquin Local Health District. ' Job Address �' City c)�CL/�/Csr/t<f Lot Size PtU! ,ems Owner's Name Address S O S i�l PhoneLl e- I C-J`I SR Contractor dtlress V 6) �' License No. Phone_ ` TYPE OF WE IPU NEVV WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR C] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL. OTHER_WELL _P_ITS/-SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .❑ Domestic/Private El-Gravel Pack - ❑ Tracy -Type of Casing Specifications. {I Public fel Other ❑ Delta Depth of Grout Seal Type-of,G out Irrigation ^_.-Approx. Defp�� /l� I-Las�tern Surface Seal Installed by - Repair Work Done [a- Type of Pump fAJ!/fi�-.a H.P. 57 _ State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 vV TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is ' available within 200 feet.) Installation will serve: Residence_ Commercial--Other' Number of living units: Number of bedrooms _ I 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 to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8r Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 .Depth Size Number L� SUMPS _ ❑ Distance to nearest: Well Foundation Property Line DISP05AL—PONDS'C76 F 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 t� 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 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 call r all required inspections. Complete drawingon averse side. Signed X Title: Data: +, OR DEPARTMENT,USE ONLY Application Accepted by Date �� Area--- N Pit or Grout Inspection by Date Final Inspection by flate/�" • Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA )NFO SH RECEIVED BY DATE PERMIT'NO. . f�111+J F//�s�r, I -� `V + EH 13-24 1REV.119 5) EH 14-26 `�"'