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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 made in compliance with San Joaquin County Ordinance No.549 for sewage or it t 1862 on for well/pump and the Rules and Regulations of Local Health District. . This application n the San Joaquin Job Address z r City Lot Size Owner's Name PM Address 34 Contractorf W Phone TYPE OF WELL/PUMP: Address *R-Pl 11 1 NEWWELL ❑ LFgense No. Phone -�WELLCEMENT : t PUMP INSTALLATION ❑ DESTRUCTION p'E DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR-0 --- SEWER LINES - OTHER O V� FOUNDATION AGRICULTURE WELL DISPOSAL FLD._ INTENDED USE TYPE OF WELL OTHER WELL PITS/SUMPS _ ❑ Industrial PROBLEM AREA CONSTRUCTION SPECIFICATIO ❑ Open Bottom —�— ❑ Domestic/Private ❑ Manteca Dia. Of Well Excavation ❑ Gravel Pack ❑ Tracy Dia. of Well Casing El Public El Other Type of Casing ❑ Irrigation ❑ Delta _ Specifications Depth of Grout Seal,' Y . ApProx. Depxh_ ❑ Eastern r Type of Grout Repair Work Done Surface Seal Installed by ❑ Type of Pump .... H.P. ,/ Well Destruction ❑ Well Diameter State Work Done_ Sealing Material (top 50');, Depth TYPE OF SIC Filler Material (Below 50') EPTWORK: 'NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system Installation will serve: Residence availablPermitted if public sewer is Commercial_ Other _ e within 200 feet.) Number of living units: , Character of soil to a depth of 3 eember of bedrooms SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ElWater table depth Clrpacity____ No. Compartments Distance to nearest: WellF Method of Disposal i _ Foundaion Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDElDistance to nearest: Total length/size Well Foundation —� Property Line SEEPAGE PITS ❑ Depth SUMPS Size ❑ Distance to nearest: Well Number DISPOSAL PONDS ❑ Foundationpro e P rty Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count or 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 Y ordinances, state laws, and employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting g 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 tion laws of California." P P The applicant m t call for all req 're ctions. Complete drawing on reverse side. Signed X Title: 11 Date: FOR DEPARTMENT USE ONLY Application Accepted by G Pit or Grout Ins pectionDate �5^"b Y Area Date Final Inspection by r Additional Comments: P Q Date ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Applicant- Return all copies to: EnvironmentalHealth Permit/Services 1601 E0 Tracy Ave., Pp, Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK 4 13-24(REV,t i a 5) ,vSe1 H RECEIVED BY DATE 4 14-2s '� oz� PERMIT'NO.