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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone (209) 466-6781 I 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 I Local Health District. f f Job Address City Lot Size PM Owner's Name ,- Alt^ ss- " Phone — 2 1 ..d L ; "Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 P PUMP INSTALLATION Q YSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINE DISPOSAL FLD. r PROP!LINE I FOUNDATION AGRICULTU WELOTHER WELL "PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA O TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom. E1 Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications I'] Public ❑ Other I it Delta Depth of Grout Seal I I P Type of Grout �. I I Irrigation _-Approx. Depth l I East n .Surface Seal Installed by Repair Work Done ❑ Type of Pump 1 H.P. -*mow State Work Done_ Well Destruction ❑ Well Diameters Sealing Material (top 50'1 +v......�,. Depth .% ,'`Filler`Material 16elow 501) _ TYPE OF SEPTIC WORK: NEW INSTALLAT ON [if REPAIR/ADDITION I. I DESTRUCTION i I .(No septic system permi7iflic sewer is available within 200 feet t Installation will serve: Residence�• Commercial Other a Number of living units: Number of bedrooms Y Character of soil to a depth of 3 feel: I _ W SEPTIC TANK ❑ Tater table depth t v Type/Mfg Capacity �No. Compartments PKG. TREATMENT PLT. ❑ I Method of Dispos Distance to}nearest: Well �o� Foundation / y Line 1/ Tie, LEACHING LINE El No. &'Length of linesVla�� Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation !2. Property Line''` SEEPAGE PITS I 1 Depth A Size Number SUMPS L7 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. t 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 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." I r. The applicant shall for all uired ins ctions. Complete drawing on reverse side. � 11 Ca . Signed X Title: )Date: u 1 I O EPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Dated Final Inspeceion by Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK j INFO CASH RECEIVED BY DATE PERMIT'NO. dj a.EH'13-24 iREWI H 5l �.� . .. EH 14-26 r ! �lol� l!