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b p APPLICATION FOR PERMIT ✓ ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 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 Ruies and Regulations of the San Joaquin Local Health District. n ✓ City Lot Size PM Job Address , i Owner's Name ss Ph ne 'J�7 p p Contr c Address License No. Phone TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack '❑ Tracy _Type of Casing Specifications 1`7 Public n Other ❑ Delta 'Depth of Grout Seal Type of Grout _ I 1 Irrigation --Approx. Depth I I Eastern .-+*Surf ace Seal Installed by Repair Work Done ❑ Type of Pump ^,H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth 'Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION (.I DESTRUCTION (No septic system permitted if public sewer is I # available within 200 feet-i Installation will serve: Residence— Commercial_ Other Number'of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 f Method of Disposal � Distance to nearest; Well Foundation Property Line --L LEACHING LINE ❑ No. & Len gth of lines ti Total length/size } FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number i SUMPS Ll 1 Distance to nearest! Well Foundation Property Line ` DISPOSAL PONDS ❑ a I hereby certify that I have prepared this application and that the work will be done in accordante'with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r Home owner or licensed agent's signature certifiei 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 11he work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t The applican u w inspections. Complete drawing reverse side. Signed X � Title: Dater 4 r FOREPARTIVIENT USE ONLY f Application Accepted by Date rp s Area Pit or Grout Inspection by Date Final Inspectio by Dat Additional Comments: y r ❑ Stk 466-6781" 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835!6385 „Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 PEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH r EH 13-24{REV.r i H 51 JNyq I L,/"Z, EH 1429 / / �ZE