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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 „_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W 1 (Complete in Triplicate) 1 1 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wogin. ication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RAO, 26 _ rt Joaquin Local Health District. �r� y ►7,, Job Address _(Z .� Y I lam, C City ;�d�E )_ Lot SizeS�✓t oCc:C? Ply) Owner's Name Address Phone Contractor Address's License Na. Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P 1. MP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excalation _ Dia. of Well-Casing ❑ Domestic/Private ❑ Gravel Pack "� ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work DonO—Type of Pump H.P. State Work Done Well Destruction, „ ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLA ON El REPAIR/ADDITION ❑ DESTRUCTIQ o septic system permitted if public sewer is T available within 200 feet.) Installation will serve: Residence_ Co mercial_ Other Number of living units: _J_ Number of bedrooms Character of soil to a depth of 3 feet: — Is Water table depth SEPTIC TANK X Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near t: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to near6st: Well Foundation Property Line i Of SEEPAGE PITS Depth Size If Number SUMPS ElDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 Calif 'a." The applican ust all for required inspections. Complete drawing on reverse side. Si ned 11 + g Title: 5_,2,ad4� Date: 10, •�t� FOR DEPS TMENT USE ONLY Application Accepted b Ver\1xey�. Date Area Pit or Grout Inspection Date Final Inspection by Data 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH11428 3-241pEV.f/B51 EH 1915 //'?/ !