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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! (Complete in Triplicate) Application is hereby made to the JSan 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. I! I. Job Address OS City Lot Size PM Owner's Name 11 Address rP lv Phone r r dl&t Contract �AddressP M License N32WI&I Phon q' TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI PUMP�IIINSTALLATION El SYSTEM REPAIR LI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca, °tt Dia" of Well Excavation Dia. of Well Casing I � ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Fid{ /'Type of Casing Specifications 1-1 'Public ❑ Other n Delta . Depth'of Grout Seal Type of Grout I 1 Irrigation --Approx. Depth l I Eastern (Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. t T�� State Work Done Well Destruction ❑ Well Diiameter Sealing Material (top 50'1 Depth ler Material Ieelo 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAI ADDITION I,/DESTRUCTION I I (No septic system permitted'if public s6v&'is gyp. ,/ available within 200 feet.) Installation will serve:. Residence_ Commercial_ the' Number of living.units: _ Number of b ms Character of soil to a depth of 3 feet:", Water table depth SEPTIC TANK - -❑ Type/Mfg Capacity No. Compartments U� PKG. TREATMENT PLT. ❑ I� Method of Disposal Distance to nearest: Well Foundation Property,Lirw 9L/ it V LEACHING LINE ❑ No. & Length of lines + Total length/size - FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGt PITS Depth Size r N�rmbejr -%- '+ SUMPS ❑ Distance to nearest: Well i Off Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that ffie work will be done in accordance with-San.Joaquin county ordinances, state laws, and rules and regulations of the San'Joaquin Local Health Diltrict. A 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 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,permii is issued, I.shall employ persons subject to workman's compensa- tion laws of California." r'- + The applican ust call fo a eq 'red inspections. Complete drawing on reverse Si 0- SignedX Title: Date: IN FOR D ARTMENT USE ONLY Application Accepted by ' Date r a ` Area IM f/j 4/� /s�t�E Gc�c. /- it r Grout Inspection by� Date -� 1. Final Inspection by Date Additional Comments: I� ' ❑ Stk 466-6781 ❑ Lodi 1�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 95201{ 4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH { -�1{ ^�vJ s.EH 13.241REV.$IN51 � ' , L 11p' r� lJ-O�OIrJS EH 14-28 `I`I