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APPLICATION FOR PERMIT jn�GcJ G SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. LJobAddress �- '` O t� V City S-1 c�-K-la Lot Size PM L Address = o A, � Phone �54-1b— C A 4�a a f-� Address + License No. Phone L `' 1Ll/ TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELLBOTHER 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 ❑ TracyType of Casing Specifications 1`1 Public ❑ Other ❑ Delta-' Depth of Grout Seal Type of Grout _ I I Irrigation _.-Approx. Depth.-'i'I Eastern urface Seal Installed by _ t. Repair Work Done ❑ Type of_P..ump + H.P. � State Work Done Well Destruction ❑ ;�VV611 Diameter y Sealing Material (top 501) Depth '"Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (') REPAIR/ADDITION I I DESTRUCTION l (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other t 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. ❑ tiw ' Method of Disposal Distance to nearest: Well Foundation' Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, slate 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 call for all required inspections. Complete drawing on reverse side. r Signed X ��MM ..�i Title: Date: _J Z, FOR DEPARTMENT USE ONLY 11 Application Accepted by Date -2 Area Pit or Grout Inspection r Dat _inal Ins tion by ate/ ate Additional Comments: 1 - ` ❑ Stk 466-6781 ❑ 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. Box 2009, Stk., CA 95201 l FEE AMOUNT DUE AMOUNT REMITTEDCK_ -� RECEIVED BY DATE PERMIT'NO. I INFO CASH + + EH 13-24(REV,I/H 5) EH 14-26