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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZE I ONF�AVE., STOCKTON, CA Telephone (209) 466-6781 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r r. r , Application is hereby made to the San Joaquin Local Health District for a permit toconstruct 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. `i 4 . M1 Y ' O°"4+ Ci Lot Size PM Job Address c - l rJff it 1 �f � ` s � Phone Owner's Name t Contractor �' N Anedess •li License No. 3�'`Y L7_Z -_Phone TYPE OF WELL/PW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR LlOTHER ❑ 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 Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca .� # Dia. of WeH Excavation �. ,DomesticlPrivate ❑ Gravel Pack - ❑ Tracy .j Type of Casing ti Specifications ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 7 Public - 1L Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed S , II Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top-50' a, kill Depth I Filler Material (Below 501) 0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O.availseptiwi hinem permitted if public sewer is i - leInstallation will serve: Residence_� Commercial_ Other t Number of living units: Number of bedrooms r ( CI r Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 9 Method of Disposal PKG. TREATMENT PLT. EDt, s Distance,to nearest: Well x •' Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size y �� S FILTER BED ❑ Distancelto nearest: Well Foundation`� '- ` Property Line SEEPAGE PITS ❑ Depth `� Size Number ; SUMPS ❑ Distances to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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.` ��It 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 to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature employ any person in such manner as 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." l 4 t The applican st caora II required Date: �. inspections`. omplete drawing on reverse side. Signed Title: (o� i� r FOR DEPARTMENT USE ONLY ' eK 6�7 Area Application Accepted by Date n f fQ � a-i _ Date �� a�0 Pit or Grout Inspection by 1 Trl ` Date Final Inspection by O Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,, CA 95201 FEE CK RECEIVED BY DATE - ZPERMIT'NO. AMOUNT DUE AMOUNT REMITTED+ EH13-24(REV.1 353q EH 14-26 - `