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APPLICATION FOR PERMIT SAN JOAQUIN^.LO�ICAL HEALTH DISTRICT _ 1 1601 E. HAZEL T ON AVE.,„STOCKTON, CA Telephone (209) 466-6781 PERMIT tXPIRES 1 YEAR FROM DATE ISSUED • (Complete in Triplicate) Application is hereby made to the San Joaquin Loi a6 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 ► Lot SizeM k i _ *� Owner's Name F'o 1 .1 Address W Phone Contractor WhL 1]AhU__1C_0�AS�Address �c7 D License No. Phone 5%a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-0 DESTRUCTION ❑ ga _ ,PUMP INSTALLATION ❑ d i STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE'� , k ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca.. +Dia. of Well Excavation Dia. of Well Casing ❑Domestic/Private ❑ Gravel Pack ❑ Tracy j rr Type of Casing Specifications ❑ Public ❑ Other ❑ Delta. ' '.rs Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Ea ern, Surface Seal Installed by Repair Work Done E3Type of Pump -H.P T l ' State Work Done Well Destruction ❑ Well Diameter a� Sealing Material (top 501 S Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residerice., - 4 Commercial_ Other Number of living units: Number of bedrooms Character of soil to a,depth of 3 feet: Water table depth SEPTIC TANK z-1-, ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LJ Method of Disposal t, Distance to nearest: Well Foundation Pro t = party Line LEACHING LINE ❑ No. & Length of lines � •'�"`"�"`��4` T�tal length/size FILTER BED„_•i ❑ Distance to nearest: Well foundation Property Line # I I k SEEPAGE PITS -❑�DeptFi� '"� Szb 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-dope-`in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.. Z:- ". ” I ' Home owner or licensed agent's signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, I shall not employny perso iin such manner as to become subject to workman compensation.laws.of-California."Contractors hiring or sub-contracting signature certifies t 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 lifo►nia." The N, plicant u ca for all equi din cti s. m late drawing on r verse sid Signed Title: `—` 6 rte.--;-•-•,.-----�---•- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date ❑ Stk 466-6781 ❑ Lodi 369t36�21�: .1'- Manteca 823-7104 1,:EJ Trac 83Fr 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 RECEIVED 9Y pA7E PERMIT'NO. INFO �y CASH + EH 1324(REV. /H 51 3 �� --C\ �� EH 14-24 V•..l J �i i