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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA it Telephone (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. y 3 Job•Addtoss Ci Lot Size PM Owner's Name00_4dress --� Phone t2i! Contractor Addres Licensee Phone r . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1:1DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE _ . FOUNDATION AGRICULTURE WELL OT L PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public C1 Other alta Depth of Grout Seal Type of Grout _ f I I irrigation _..Appio pth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ T Pump H.P. State Work Done_ a Well Destruction Well Diameter Sealing Material [top 501 Depth - ' Filler Material (Below 501 } TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t.I DESTRUCTION o septic system permitted if public sewer is A available within 200 feet.l ,d Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character'of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.`TREATMENT PLT. ❑ i� "'"F-"" Method of Disposal Distance to nearest: Well Foundation Property Line iP LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well J Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: 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 no I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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." [11 f _The applica t ust call for all require "ns ctia s. Complete drawing on�ee si w f: Signe Title":Title: Date: ` - FOR. PARTMENT USE ONLY *' Application Accepted by A5 Date C7 ' Area —� ILI .. - _ y AV i Pito Grout Inspection by I' Date Final Inspection by Dat ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi i�.369-3621 ❑ 91antoca 823-7104 ❑ Tracy 83F ---- Applicant - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE A DUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH �y G c + EH 1324IpEV.riasr S S '(J� 4-7 �47 EH 14-28