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VV D 3 '� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.`, STOCKTON, CA �u-�-- x 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.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. q5 4 1 LJob Addre s.- s t CiSLI PM Owner's Nam Address P > Phone / Contractor w Address "PO &-k k/l.t 27ense No./— 13 hone v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ / --DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LY OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINIr FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ir00strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation /_Approx. Depth ❑ stern Su ace Seal Installed by Repair Work Done 8� Type of Pump , H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION p DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No.;Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �0 Distance to nearest: Well�_ Foundation T Property Line (\ LEACHING LINE ❑ No. & Length of lines '' Total length/size FILTER BED ❑ Distance to nearest: Well------7— Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 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'regglati a aquin Local Health District. Home owner icerlsed agent's sign ture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any arson in such manner a to become subject to work compensation laws of California."Contractor's hiring or sub-contracting signature' certifies th following:"I certify the the perfo man�Xk/,&/wh' this permit is issued,I shall employ persons subject to workman's oorrlpensation laws, f California.''The appli nt m all quired i e oxvverse Signed Date: ltelff OR DEPARTMENT US ONLY l Application Accepted by — \ Date Area Pit or Grout Inspection by Date Final spection by � Date Additional Comments: 1191, ❑ 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 INFO 1 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIV NO. + EH 3-24 14-ZB(REv.1/e5) L� S , Icy EH — 1 i