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�0 WCL. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - r3 -(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. 1862f or well/pump and the Rules and°Regulations of the San Joaquin Local Health District.:,r i I , L1 Jab Address r �+�— i City Lot Size PM VAN Owner's Name Address Phone ContractorAddress-- - �— — License No. Phone TYPE OF WELL/PUMP: -NEW WELL ❑,. WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑. SY37EM AEPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL !r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS ❑ Industrial ❑ Open Bottom' ❑ Manteca"" "bio`of Well Excavation Dia. of Well Casing ;l ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy___, Type of Casing I Specifications ❑ Public 4 El Other El Delta , Depth of Grout Seal-`s Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern ` Surface Seal Installed by Repair Work Done ❑ Type of Pump '71 P. r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth f -- —'Filler-Material (Below 50') { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION is system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence— Commercial Other IN Number of living units: Number of bedrooms Character of soil to a'depth'of3 feet: Water table depth I SEPTIC TANK `4;�ype/Mfg I�1t1C�"F� i Capacity No. Compartments PKG. TREATMENT PLT. ❑ i / •' ° Method of Disposal Distance to nearest: Well Fo ndation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth -Size Number SUMPS ❑ "Distance to nearest: Well Foundation Property Line { ,j]ISPOSAL PONDS ❑ i + 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 rulBs'and regulations of the San Joaquin Local Health District. j , I ("s , ' 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 amp o ny person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifieb,th folio " rtify 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 ifornia.' T applica t m t all for a req 'red in ction C plete drawing o averse sid Title: Date. Signe F DEPARTMENT USE ONLY f} Application Accepted by _ Date 2 Area Pit or Grout inspection by Date Final Inspection by Data13 � i. 1g�4 Additional Comments: Vr ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT N0. INFO + EH13.24(REV.r/a s1 `,. b�G�O bs . EH 14-28 i —r7—