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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r+' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i .. 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 Rules and Regulations of the San Joaquin Local Health District. ` 33S Job Address e City / Lot Size PM Owner's Na Address rZPhone M, Contractor Address cQS23 J5 License N Phone �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: ,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LI FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP IONS i ❑ Industrial ❑ Open Bottom ❑ Manteca�Dia. ofvation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Specifications C,1 i"i Public ❑ Other' ❑ D Depth of Grout Seal Type of Grout Wr I i Irrigation __-Approx. D I I Eastern "o Surface Seal Installed by w Repair Work Done ❑ T ump H.P'. State Work Done _ Well Destruction Well Diameter Sealing!Mate?ial (top 501 ; Depth Filler MateriallBelow 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION Il REPAIR/ADDITION L I DESTRUCTIO o septic system permitted if public sewer is _ a ailable within 200 feet.) Installation will serve: Residence Commercial� Other r " Number of'Wing units: Number of bedrooms f Character of'soil to a depth of.3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg - -- Capacity No. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line is I {{ LEACHING LINE ❑ No. & Length of lines '� ( r ? Total length/size f ; € FILTER BED © Distance to nearest: Well r l I ! Foundation Property Line SEEPAGE PITS I I Depth Size ' Number SUMPS D Distance to nearest: Well FounLion Property Line j 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 istrict- -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 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i 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." F The applicant ust call for all required'inspections. Complete drawing on reverse Signed X 141Title: Date: FOR DEPARTMENT USE ONLY Application Accepted.by DateA_tf � Area Pit or Grout Inspection b �`� �"�" " /D pe y Date Final Inspection byDate �Additional Comments: O ❑ Silk 466-6781 ❑ Lodi 369-3621 T]Manteca 3 823-7104�,�k f ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { FEE INFO 'AMOUNT DUE AMOUNT REMITTED RECEIVED,8Y DATE PERMIT'NO. 00 + EH 13-29(REV.I/n 51r �l `/ EH 14-24 J