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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I'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. Joh Address O � City (X. '/Lot Size PM Owner's Name e ✓Z Address [ N Phone Contractor Address License No. Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT V01, DESTRUCTION ❑ PUMP INSTALLATION ❑ XAGRICU SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S SAL FLD. PROP, LINE FOUNDATION RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARENCa ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaExcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C1 Tracy " g Specifications f`l Public 71 Other F1 Delta out eal Type of Grout_ I I Irrigation _.-Approx. Depth 1 1 Easternl Install byRepair Work Done ❑ Type of Pump H.P. ateWork DoneWell Destruction ❑ Well Diameter Seafi50')Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION i_I DESTRUCTION INe septic system permitted if public sewer is available within 200 feet.I 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( l Depth Size Number SUMPS D Distance to nearest: Well f=oundation 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 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 thef lowing: "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 Cal ornia." The appli ant m t call-or, I r quire spectio o lata drawing on reverse side. Signed X Title: Q M�� Date: Z & FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by Data Final Inspection by��7/S�//'1 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �� CASH J[ (//1�� //�/ly� +.EH 14-26 IREV.t!n5Y t _Z) l Ic � 1'P`[ q i� EH 19-2tS