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f ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F 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. I Job Address / City Lot Size PM Owner's Name DSD / Z Address 4, Phone �v 2 Contractor -5e Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION El PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER O see-111 ce DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 5'yr5 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �b INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑`Gravel Pack ❑ Tracy Type.of Casing Specifications �e FI Public: ❑ Other F1 Delta DepW,of Grout Seal Type of Grout _ I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top.501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Irl REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 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: 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 BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 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 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 tF a followinj3:C"I"certify thavin the performance-of the.work for.which.this_permit..js..issued,-1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for al wired a ctions. Complete drawing oh re erse side. t - Signed X Title: Date: _l _ oc —0 10 FOR DEPARTMENT USE ONLY `. Application Accepted by Date 6�7"� Area o� Pit or Grout Inspection by Date Final Inspection by /Date Gr/p �►. sna�w��rv�ur/S' f S 67r 7� aS'�r rrc� w�'iib Ste!-Ns Additional Comments: y�isT57� ��- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 0}. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY -DDATE PERMIT N0. +..EH 13.241REV.iies) 7Qi D® J �"V 0 /(/ ,� ��.>.>T� EH 14-26 g-If.7 A0f AaAP& 19eer-) ;t+5A ICS