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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT, -1601 E. HAZELTON AVE:, STOCKTON, CA Telephone (209) 466-6781 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. c ,/�, c 4 re' 7 Z istr Job Address i .J �V�.i City �-+ Lot Size V PM Owner's Name w- Address Phone y c ��]��^� I L.+ Li se N / a Phone O Contractor �-�`" —Address IN E: Ck/��} n TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC /► �/ ❑ Ind ral' ❑ Ope ttom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 omestic/Private ravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �T pe of Grout l ❑ Irrigation ' ---Approx. Depth ❑ astern Su ce Seal Installed by Repair Work Done ��Zelel of Pump H.P. State or o e Well Destruction Dia e er 4* Sealing Material (top 50'1 jul Depth Filler Material (Below 501 10 P' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available septic system permitted it public sewer is � available within 200 feet.) \f lnstallatiori will serve: Residence_ Commercial_ Other �.— ' Number of living units: Number of bedrooms �s ' Character of soil to a depth of 3 feet: Water table depth { SEPTIC TANK ❑ Type/Mfg Capacity__------L No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Gine t LEACHING LINE ❑ No. & Length of lines Total length/slze FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number " 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 I , rules and regulations of the San Joaquin Local Health District. I 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:' ce th in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califo The applic st I all r i nspections. Complete drawing on reverse side. i Title: Date: 1�— Signed FO D RTMENT USE ONLY Application Accepted by Date'-"" A Pit or rout spection by a rnal Inspection by Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 • a FEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE FPERMIT'NO.'INFO ` -7t EH 13-24(REV.1/e s) 1 Q C..?. "J - �/Z' � � EH 1428