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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON-AVE., STOCKTON, CA PAYMENT 43 Telephone (209) 466-6781 RECEIVED F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB 14 1903 (Complete in Triplicate) F�f n Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wolit h APmade in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an 11in is Local Heakh District. �T ��tMTquin i Job Address Cit IZ 2Gr^e r1�� t� Y Lot Size PM f Owner's Name 6 b �'t Yt/l Address 7l phone 5"Q Contractor S12 Address ' License No, Phone_ TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTfON ❑ PUMP INSTALLATION"JR SYSTEM REPAIR ❑ OTHER ❑ —DISTANCE TO NEAREST: SEPTIC TANK--- ,SEWER.LINES DlSPOSAL.FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C Open Bottom ❑ Manteca Ria, of Well Excavation Dia, of Well Casing IR Domestic/Private ❑ Gravel Pack 2(Tracy Type of Casing M PublicSpecifications F1 Other ID Delta Depth of Grout Seal I I Irrigation Type of Grout _ —.Approx. Depth I I Eastern .surface Seal Installed by Repair Work Done El Type of Pump --a/s�_ L� H p - State Work Done_ a Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth K Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION 1"I REPAIR)ADDITION l 1 DESTRUCTION i I (No septic system permitted if public sewer is I . Ilatfon will serve: Residence— CommercialOther available within 200 feet.) Number o units: Number of bedrooms Character of soil to a of 3 feet: SEPTIC TANKWate a depth ❑ Type! Capacity PKG. TREATMENT PLT. EJ 0. Compartments Method of Disposal Distance to nearest: Well F Property Line LEACHING LINE ❑ No. & Length ` Total length/size FILTER BED ❑ Di to nearest: Well Foundation Property-Line ti. SEEPAGE PITS Depth Size Number � SUMPS.-- ... - --❑ Distance-to well- Foundation - ;:Property-Line DISPOSAL PONDS ❑ 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." 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 inspection omplete drawing on reverse side. Signed X Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date ( ! Area (J Pit or Grout Inspection by Date Final Inspection Date Z�'d Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104y ❑ Trac 635-6385 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 INFO RECEIVED BY DATE PERMIT'NO. +.EH t3-24 tREV.i i e sl n EH 14-26 `77