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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT � en e- 1601 1601 E. HAZE;_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. Job Address ✓ City Size PM �r 1 Owner's Name r Phone &46�j �r} ContractorNo. Phone (/ TYPE OF WELL7pump.1 NEW WELU❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. OP. LINE FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC S ❑ Industrial Ll Open Bottom C1 Manteca Dia. of Well Excavat Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ca ' Specifications ❑ Public ❑ Other ❑ Delta of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth, Filler Material (Below 501 TYPE OF SEPTIC WORK: W INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted ' ublic sewer is `. - x available within 200 feet Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms' Character of soil to a depth of 3 feet: er table depth T) SEPTIC TANK ❑ Type/Mfg �Cao�C1 ompartments PKG. TREATMENT PLT. ❑ _� y4 ad of Disposal Distance to nearest: We arm d o iligm� Line V � 76 �-, LEACHING LINE ❑ No. & Length of lines [ io{ FILTER BED ❑ Distance to nearest: WeUTLn mi 6j GT 19T uDM3j@1RyLine SEEPAGE PITS Depth SizeNumber DSUMPS nearest:nc,to I Well Foundation Property Line DISPOSAL PONDS I hereby certify that I ve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulatjo s of the San Joaquin Local Health District. t Home owner,.of'licensed agent's signature certifies the following: "l 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant` c I f eq in ctio Completed on erse side. Signed " y le• Date: FOR DEPARTMENT-USE ONLY Application Accepted by Date Area ! v Pit or Grout Inspection by Date Final Inspection by Date Additional Commen ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823- 104 ❑ Tracy 835ZM Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 I1 7 req z-- S� -4mv- ha( beei d adFEE INFO MOUNT DUE AM UNT REMITTED CASH RECEIVED BY DATE PERMIT NCO. jj}519cc.•r7�/i� + EH 13-24 TREY.1/a sl 4•"-' �`— EH 1448