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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 N PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED 0, 1C�S (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. 4.Z�gl ° - '- �'" Dts� 673--o r Job Address I City ,ot Size PM Owner's Name Address �7 L]T>� Phone Contractor �IVL{,-rull"ff/ ` �4ddress 1WWAv � �j, 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENt ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i - 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 --b Public n Other f1 Delta Depth of Grout Seal Type of Grout E 1 Irrigation q C J _. pprox. Depth i I Eastern Surface Seal Installed by E Repair Work Done ❑ Type of Pump2 �-N_ H.P. State W Done Well Destruction ❑ Well Diameter 'r i � Sealing Material (top 501 l " Depth r Filler Material (Below 501 [? TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 Q SEPTIC TANK LJType/Mfg Capacity No, Compartments `1► 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 E SEEPAGE PITS I l Depth Size Number I 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 Di§tfict. 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 the&follng 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 ofThe applicafor all re -d inspec ns. Complete drawing on"rreverse,side, Signed X Title: t� Date: OR DEPARTM USE ONLY w � / Application Accepted by Date J Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ T ❑ Stk 466-6781 ❑ Lodi-369-3621 ❑ Manteca 823-7104 ❑ Tracy: 835-6385 R 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 DATE PERMIT'NO. +.EH 13-24(REV.r/K51 ZoP(?-.-1 � EH 14-28 3-5 �d 1