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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Cbb.2--, Telephone (209) 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heiaby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. 4 Job Address City. G2".— Lot Sizer PM 4 Owner's Name 1 Address - /F!. � 'If/�J �' ",Phone t Contractor �'/' u" Address "' '7'LM? 77 7 L 'e License No. Phone TYPE OF WELL/PUMP: NE ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION IJ .= PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 �\ 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SpecificStions I'I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ y Irri41ation _—_Approx. Depth 1,1 Eastern Surface Seal Installed by ,f Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter " Sealing Material (top 50') Depth Finer Material f8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRIADDITION I I DESTRUCTION (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 �I Character of soil toa depth of 3 feet: Water table depth p SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance ito nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED C1 Distance to nearest: Well Foundation Property Line A SEFPAGE PITS I I Depth Size Numbar SUMPS 1-1 Distance}to nearest: Well Foundation Property Line DISPOSAL PONDS LI 1 I herebycertify that I have p pp Y 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."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." The applicant must c all requir r9Pf5&ons. Complete drawing on reverse side. Signed X — !— Date: .� I FOR DEPARTMENT USE ONLY Application Accepted by - !"•"•� � -1 ,r Date r � / C�� - Area Pit or Grout Inspection by Data Final Inspection by Date - Additional Comments: ❑ Stk 466-6781 1J Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bort 2M, Stk., CA 95201 ( I FEE { INFO AMOUNT DUE AMOUNT REMITTEt} CASH RECEIVED 8Y DATE I PERMIT'M0. EH 13-24(REV.rin5i EH 54-28 ..s' 7' " - '! /,.�•'' /�r'f 1. i / 1��