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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PTD PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hetehy 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. i Joh Address" � �r City Lot Size/ "' — PM Owner's Name Address Phon ✓ �� ,` A 1 Contractor Address-44 nser IVo. Phone /O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open-Bottom L1 Manteca'1� Dia. of Well Excavation Dia. of Well Casing r� [D Domestic/Private i] Gravel Pack ❑ Tracy Type of Casing Specifications �\ FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ` I I Irrigation ._._-Approx, Depth I i Eastern Surface Seal Installed by _ c .Repair Work Done ❑ Type of Pump H-P. `s State Work Done.; "w Well Destruction Well iameterSealing Material [top 50'1 r Depth Filler Mate' l'lBelo w 50') T (\ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 R/ (TION l I DESTRUCTION I l INo septic system permitted if public sewer--is \1 t..available.,within 200 feet.) REPAIR/ y Installation ill serve: Residence_ Commercial Other Number of living units: Number of bedro ms { �, Character ofisotl to a depth of 3 feet:`. - e Water table depth SEPTIC TANK* ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ '<, Method of Di al "* Distance to nearest: Well Foundation `Property Line LEACHING LINE ❑ No. & Length of line Tial length/size FILTER BED ❑—Distance to nearest:_,... Well Foundation ��// Property Line `/ jr SEEPAGE PITS I'! Depth _ZA Size Number r, SUMPS ❑ Distance to nearest: WellMAO 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." Contractors 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 pnList cal r all re wired ir c ons. Complete rawing onnr/j rs side. Signed Title: [/ Date: v FOR DE ARTMENT USE ONLY 9 Application Accepted by Date ea for Grout Inspection by ate Final Inspection by Date&A/,,�—F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 6 -3621 ❑ Manteca 623-7104 ❑Tracy 835-6385 j ! Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box tk., CA 952f, FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24/REV.t/+t sl EH 14-28 0 �� `-' 1 Li4