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Fw. APPLICATION FOR PERMIT 1� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (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 Rules and Regulations of the San Joaquin Local Health District. Job Address /1J City Lot Size _I`" PM Owner's Name ddress Phone Contractor— Address icense No. DCf._S'Phon � TYPE OF WELL/PUMP: NEW WELL Q WELL REPLA MENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ 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 Sea] Type of Grout — '_ Q i I Irrigation __-_..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material ( elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION k DESTRUCTION I I (No septic system permitted if public sewer is L available within 200 feet.) Installation will serve: Residence Commercial� ther j! Number of living units: Number of be4rooms Character of soil to a depth of 3 feet: G Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _,"'Foundation._.-_3 0_ Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well f Foundation_ T Property Line _ SEEPAGE PITS it Depth Size Number SUMPS Ll Distance to nearest: Well /-4%2 Foundation 140Property Line S:-- 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: "1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The appti must all r all re ired i9flpections. Complete drawing on reverse side. Signed X Titre: , Date: a� r0� FOR D PARTMENT USE ONLY Application Accepted by Date Area or Grout Inspection b ate Final Inspection by Date -27• 141yg (/Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEE AMOUNT DUE AMOUNT REMITTED INFO ��77 CASeHf RECEIVED BY DATE PERMIT�NO. + EE 3-24 H14-2BIREV.tiN57 /JI c© ��7 �1�'j 1�"� `T��' Ip[r-32- Q