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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address �� c City� Lot Size PM / Owner's Name //[d/Z-[QJ✓t : •/i[�v r �wU Address ��/ �3 Phone 434-16' " Contractor Address •O License No. Phone TYPE OF WELL/POMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ fiSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ti FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Q Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. State Work Done 1 Well Destruction . ❑ Well Diameter Sealing Material (top 50') (1 Depth Filler Material iBelow 501 _ TYPE OF SEPTIC WORK:�NEW:INSTAL TION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted•if public sewer is) �.. available within 200 feet.) r" Installation will serve: Residence_ Commercial_ Other ✓ , n Number of living units: Number of bedrooms 1/ 1 Character of soil to a depth of 3 feet: Water tattle depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method o� Disposal h� Distance to nearest: WeII -- _ .,Foundation -v - Property Line� �1 LEACHING LINE ❑ No. & Length of lines Total length/size Q FILTER BED ❑ Distance to nearest: Wall Foundation Property Line i --1NI SEEPAGE PITS ❑ Depth Size 4' Number SUMPS ❑ Distance to nearest: Well Foundation -A— 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. f Home owner orlicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r&Mploy any'person in such manner as to become subject#o workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify.'that in the performance of the work fo�,wfiich this permit is issued, I shall employ persons subject to workman's compensa- tion l I, of CalifoTn .; The applicant m st call for all required:inspections. Complete drawing on reverse side. Signed Title: Date: / J 1 � � FO�DEPATNMENT U5E ONLY Application Accepted by , `I!' Date r Area + Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3699-3621 ElManteca 823-7104 ❑ Tracy 835-63135`.,,1 Applicant- Return all copies to: Environm ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4� RECEIVED BY DATE: PERMIT•'NO. t f INFO + EH13-24IREV.fia57 EH 7426 (tJ