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z APPLICATION FOR PERMIT 7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA CIO Telephone (209) 466-6781 ZI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ',. (Complete in Triplicate) LMlication is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hFWAIT I San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and thdENFE � l Local Health District. r` City3`'�"`' Lot Size PM Job Address [p� �•7 [� �-.�p� Owner's Name n C7 Address r.�*' /�� 4`- � Phone �e Contractor � �'�'�'`�' __Address t`G' A � '� License Nd�'Z3 2� Phone t 61 TYPE OF WELL/PUMP: NEW WELL ❑ i' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION;SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom IJManteca Dia. ,fW.11 Excavation Specifications ❑ Domestic/Private El Gravel Pack ❑ETracy Type of Casing t Type of Grout FI Public ❑ Other FI' Depth of Grout Seal Yp I I Irrigation Type of Pump—.Approx. Dept I I`Eastern._ Y Surface Seal Installed by ❑ -``, .H p �' State Work Done Repair Work Done Well Destruction ❑ Well Diameter ,Sealing Material (top 501) 3 -Depth - - - '"Filler-Material (Below 501 TE OF SEPTIC WORK: NEW INSTALLATION I1' REPAIR/ADDITION I I DESTRUCTION i I avlo sepeiwthin 200 feetstemit�ed if public sewer is YP Installation will serve: Residence— Commercii al — Other I Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments w I PKG. TREATMENT PLT. ❑ Method of Disposal i i Distance to nearest: � Well ' Foundation r �;! Property-Line i LEACHING LINE ❑ No. & Length of lines ( Total length/size FILTER BED ❑ Distance to nearest: i Well Foundation Property Line i SEEPAGE PITS I I Depth Size ! Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 taws of California." Contractors 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." 1 I S The applicant st c 11 for all required inspections. Complete drawing on reverse side. I `� �_r,A) yv�-.// l Date: Signed X �4i-1 rtto: `FOR DEPARTMENT USE ONLY I Date ` Area Application Accepted by t Pit or Grout Inspection by Date Fina! Inspction by 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 CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH a.EH 13-21(REV.I/w 51 /a EH 14-26 F