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APPLICATION FOR PERMIT ,� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1''YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 h i City Lot Size _ ,. (� PM Owner's Name ress Phone U ®/�7t-3 Contractor Address License NoOyz/.Phone 40 T,� TYPE OF WELL/PUMP: �,. NEW WELL ❑ WELL REPLACEM T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS 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 M Public L] Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth I-I-Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump. H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 1 U Depth Filler Material (Belo)Y4.) TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence Commercial— Other — F Number of living units: .. Number of bedrooms. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg rlCapacity No. Compartments PKG. TREATMENT PLT- ❑ V ► Method of D- osal Distance to nearest: Weil V Foundation ' �� Property Line LEACHING-LINE ❑ No. &Length of lines Total length/size FILTER BED EIDistance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth 1V y Number SUMPS t ❑ Distance to nearest: WellFoundations Property Line --` SPOSALPONDS ❑ ! 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. 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thisermit is issued, I shall employ tion laws of California," p p Y persons subject to workman's compensa- tion The applicant u Ii f all re ired inspections. C 'plate drawing on reverse side. i Signed X Title: Date: .� OR DEPARTMENT USE ONLY tI Application Accepted by hhNaA Date �— 4 � t A as + Pit or Grout Inspection by Date Final Inspection by `� Date �� Additional Comments: t ❑ Stk 466-6781 ❑ Lodi -369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i `I FEE MOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. + EH13-24IREV.tin51 ,/-i^.14111 EH 14-26 � Lf— 1.96-7 .9j 7+ MIS L.#j