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APPLICATION FOR PERMIT s n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � � � Telephone (209) 466-6781 e , PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) . Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d cribed. h1s applrcatron is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. r 7 1} City S7i�T N Lot Size PM Job Address �r' A/ ' r7 Owner's Name �f/V G Address 6 / ]r Phone G3 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ EWER LINES _ DISPOSAL FLD. PROP. LIN DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL /SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION TIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia I a Excavation Type of CasingSpecifications ❑ Domestic/Private ❑ Gravel Pack ❑ Trac yp Type of Grout—.--. i"l Public F1 Other elta Depth of Grout Seal _ } I Irrigation _A epth l I Eastern Surface Seal Installed by H.P. State Work Done _ ! Repair Work Done 1-1peof Pump - Well Destructi ❑ Well Diameter Sealing Material (top 50') E Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i-I DESTRUCTION ) alvailablerwi hin 20system 0 feet.) d if public sewer is Installation willserve: Residence Commercial -Other li Number of living units: Number of bedrooms Water table depth i Character of soil to,a depth of 3 feet: SEPTIC TANK Cl Type/Mfg Capacity No. Compartments Method ot,,Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line l LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r 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, state laws, and I rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, 1 shall not signature employ any person in such manner as to become subject to workman's compensation laws ss California." ploy ceasonsrsub cring rt to workman'sogcompensa- certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." T icant st call for all re uired inspections. Complete drawing on reverse side. ��iP Signed X Title: AA I&) Date:,:7-z FOR QQART7 MENT USE ONLY — � Date 1 Area � 0 Application Accepted by f/x�Z Pit or Grout Inspectio Date Final Inspection Dateyv u 1 Additional Comments: ` ❑ 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 1 FEEAMOUNT DUE AMOUNT REMITTED CK , RECEIVED BY DATE PERMIT IVO• INFO ^f + EH 13-24 JREV.t i n 51 Z;5c�-` EH 14-28