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APPLICATION FOR PERMIT SAN JOAQUIN LOCAijHEALTH DISTRICT t. n.:'. 'E-1 , . ,'.c+ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - {Complete in T^rjpljcate) 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 Miles and Regulations of the San Joaquin Local Health District. r Job Address g'�City' Lot Size &4PM Owner's Name ddress '-Phon Contractor -ed/�,,ddress #&20 E License Noaaw Phone" —.33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , F PUMP INSTALLATION' SYSTEM REPAIR El OTHER LlI DISTANCE TO,NEAREST.,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indu_st;ial � - F-1 Open Bottom ^ �^ ❑ Manteca "'""Dia. of Welf`Ezcavation Dia:of Well Casing Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications 1` L] Public L2 Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Irrigation —Approx. Depth Eastern! Jurface Seal Installed by Repair Work Done ❑ Type of Pump � �H.P, State Work one Well Destruction ❑ Well Diameter SeMing-Material (top X50') r Depth +Filler Material,IBelows50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-L] DESTRUCTION ❑ (No.septic system permitted if public sewer is C-,- } — � 1.0 ;available within 200 feet.) Installation will serve: Residence Commercial— Other �' l Number of living units: Number of bedrooms 4 � Character of soil to a depth of 3 feet! Water table depth (� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments }t . PKG. TREATMENT PLT. ❑ Method of Disposal w4 Distance to nearest: Well Foundation Property Line I I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Elr ter` 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 and, i Houle 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 sdbject 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,I shall employ persons subject to workman's compensa- tion laws of California." I The applicant mu call for all required i spe tions VC mpl to drawing on reverse side, i Signed. _ - - ''- �^�^-Title:-"r Date: 0 FOR DEPARTMENT-USE ONLY Application Accepted b ' + "[~ AO�'Q 1� pP P y Date Area Pit or Grout Inspection Date Final Inspection by Date / rr 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 95201 IFFE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1344 1REV.1/8 57 EH 1426 '�� O .•r/