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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) AUG f � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein degriW application is made.in compliance with-San.Joaquin County Ordinance-No:549'for sewage or No. 1862 for welUpump and thesarld Regulations oft the an Joaquin Local Health District MENrA� Pin HEALTH „F � � LI '� r MiTISERVr Air Job Address t z., City Lot Size C��M Owner's Name t/1. L Address tj1^ 11T'&Ct1 Phone 4 - y E Contractor ddtess rise No. o�0 --_Phonecs TYPE OF WELL/PUMP: V NEW WELL`K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK (TD SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA , CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'Domestic/Private XGravel Pack Tracy Type of Casing, �1/P� Specifications FI Public ❑ Other n Delta Depth of Grout Seal f Type of Groui I 1 Irrigation 9AN—r- )pprox• Depth I-1 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 1121e10w 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is QQ 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 C) Distance to nearest: Well Foundation Property.Line a LEACHING LINE ❑ No. lit Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line M SEEPAGE PITS 11 Depth Size Number f 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 I 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 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 The appl' ant ust call for all requira4 inspections. Complete drawing noer a sid �7p Signed tle: —.Date: f p DEPA ENT USE ONLY Application Accepted by Date ' Area Pit o Grout nspection by Date 2 Final Inspection by Date Additional Comments: - 0 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 r IFEE AMOUNT DUEU AMOUNT REMITTED RECEIVED BY DATE PERMIV NO. ; INFO CASH ppp ry�y, 7 +.EH13-21(REV.t i n 51 � 7 o — a EH N-26 LLL r