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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR 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. City a // m/ Job', ress C ty Lot Size/ � PM Owner's Name l Address l / �12-2, Phone it Contractor AddressZA,7L Q_ _License No. Phone TYPE OF WELL-/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPINSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO.NEAREST:-SEPTIC.TANK SEWER LINES DISPOSAL FLD PROP. LINE z FOUNDATION AGRICULTURE WELL OTHER•WELL PITS/,SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ..Dia.-of Welt-Casing 4 ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications [n F-I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - f l Irrigation _Approxi Depth I I Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Materia! {top 501 t Y Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTIONINo septic system permitted if public sewer is , r available within 200'feetj} Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feett Water tabledepth' SEPTIC TANK ❑ T 4 YPe/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal 'Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth f Size _.Number SUMPS 0 Distance sto nearest: Well Foundation Property Line DISPOSAL PONDS Elt _ ' 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 rules and regulations of the San Joaquin Local Health Dri1trict. Home owner or licensed agent's signattire 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: "I certify that in The performance of the work for which.this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." TheaLica call for aid required! ctionComplete drawing on r side. Signed_ Title: Dater I FOR DEPARTMENT USE ONLY Application Accepted by 10'6L _- Data ' Pit or Grout Inspection by Date Final Inspection byData Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AAMOUN/TTREMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH1 -24{ftEV.i/a5) EH 1429 /zpS .