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APPLICATION FOR PERMIT < SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1601 E. HAZELTON AVE,, STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. t , ; Job AddressQ�,_ �_C,a___ City ^ o Size PM Owner's Name ` --� Address � M 2-6 Phone 01 0cv Contractor Va )—nAA:A O rn ( Address License No. Phone— TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION P!9- -SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATID S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat' n Z Dia. of Well Casing I VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - �0 Specifications I`I P\ublic ❑ Other la Delta y`{ Depth of Grout Seal: _S, Type of Grout _. C I I irrigation ---Approx. Depth I I Eastern y Surface Seal Installed by I [��lJ Repair Work Done ❑ Type of Pump H. State Work Done [\ Well Destruction ❑ Well Diameter Sealing Material (top 50') °J Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial._ Other - 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ( PKG. TREATMENT PLT. 0 Method of Disposal Q ` Distance to nearest: Well Foundation Property Line N LEACHING LINE ❑ No. 11 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LlDistance 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 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 such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 Calif r The applican u call for ctions. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY (q Application Accepted by Date ZI d/ Area Pit or Grout Inspection by Date v� Final Inspection by v Date 7 Additional Comments: A it ❑ Stk 466-6781 El Lodi 369-36 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. 2� ♦.EH13- IREV.,in51 EH t4-29 w 3