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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ., 1601 E. HAZETON AVE., STOCKTON, CA i Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED en '' (Complete in Triplicate) i 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. Job Address – '[ SS J "1 f�� City ro Lot Size PM Owner's Name Address c• ,,..,. ._ Phone r Contractor ` c Address License No. Phone ,TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r_PUMP INSTALLATION ❑_, SYSTEM_-REPAIR ❑ _ __ OTHER _❑_ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i .DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLII PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia: of Well Casing ❑ Domestic/Private L7 Gravel Pack ❑ Tracy Type of Casing Specifications (I Public 11 Other i n Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approxi Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ T p p Type of Pum H.P. State Work Done r Well Destfuction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) `s �Installation will serve: Residence Commercial __ Other j " "Number of living units: Numberof bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg', Capacity No. Compartments PKG. TREATMENT PLT. Cl _ Method of Disposal { Distance to nearest: WellFoundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: _. Well = Foundation - Property Line SEEPAGE PITS `"r y :I i Depth Size t Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOS41-TONDS ❑ { ' I hereby certify that I have prepared this application and tfiat 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. 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 suc a ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foliow1 : 11certif that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion la o is Th ppli nt II all to I d c ion pla yawing on reverse side. igned .X Title: Date; A �. FOR DEPARTMENT USE ONLY I Application Accepted by Date Area Pit or Grout Inspection by 0!130 Date Final Inspecti by p i Additional Comments: El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 o � s K i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED B DATE PERMIT'NO. � Q��7' f�J P7 + EH 114-28 3-24 TREY.I/n 51 EH - ?.s �� ] -�I ��X2 J fi '