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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 TYEAR FROM DATE ISSUED (Complete in Triplicate) y 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 weIN pump and the Rules and Regulations of the San Joaquin Local Health District. OT dr City Lot Size PM Jo_b Address -7'yG Owner's Name /�A4_ � � Address Phone W2"' xllo q ' / ,rc t �l� Phone! "rl Contractor i e*ft gu' Address �53� �, License No TYPE OF WELLIPUMP: NEW WELL_L7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. xcavatRia. of Well Casing ion � L] Domestic/Private ElGravel Pack ❑ Trac Type of Casing Specifications I 71 Public Cl Other Delta Depth of Grout Seal Type of Grout — I ( Irrigation x, Depth t i Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 r Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION {.l REPAIRlADDITION 1.1 DESTRUCTIO Iperm Nailabpti7ab system ithinper feet.) if public sewer is t Commercial— Other Installation will serve:" Residence Number of living units: Number of bedrooms e7 - p. Character of soil to a depth of 3 feet: Wapth I SEPTIC TANK ❑ Type/Mfg Capacity Noents PKG. TREATMENT PLT. ❑ Meposal ,Distance to nearest: Well Foundation Property LEACHING LINE µ Cl 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 L1 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 Sart 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, 1 shall not Ik of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's compensation laws 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." d inspections. Complete drawing on reverse side. The applicant must call for all require �7 k Signed X Title: Date: , FOR DEPARTMENT USE ONLY I Application Accepted by Date w Z Area Date Final Inspection by Date Pit or Grout Inspection by y Additional Comments: , ? ❑ Stk 466 6781 ❑ Lodi 1 17- 17 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. INFO r l + EH 13.24 tHEV.1/A 51 r.p` �,S U / !/ _?461 61 EH 14-26 ✓-�