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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT L S .f-4 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781tV ;✓z a- . �-tl �^ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I f (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, { Job Address ] 1 Cit of Size Owner's Na Address Phone Contractor ' rens f FTYPE OF WELL/PU P. NEW ELL CIPhony WELL REPLACEMENT ❑ nse NoDESTR TION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK � OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ❑ PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca i ❑ Domestic/Private ❑ Gravel Pack Dia. of Was Excavation Dia. of Well Casing � ] 1 CJ Type of Casing ** F M Public I1 Other 171 DeltaSpecifications Depth of Grout Seal �V' 1 I I Irrigation —.Approx. Depth I I Eastern Type of Grout Repair Work Done p T Surface Seal Installed by G ` Type of Pump H.P. State Work Done ! Well Destruction ❑ Well Diameter ealing Material' Itop 501) C Depth Filler erial (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR DDITION 1.1 DESTRUCTION I I INo septic stemqsewp, 1 �{ P Y permitted if Installation will serve: Residence_ Commercial Other available within 200 feet.) Number of.living units: Number of bedrooms i I Character of soil to a depth of 3 feat: M SEPTIC TANK Water table depth❑ Type/Mfg PKG. TREATMENT PLT. ❑ Na. Compartments Distance to nearest: yt/ehMethod of Disposal I Foundation property Line F, t LEACH)NG LINE ❑ No. & Length of lines FILTER BED Total length/size Distance to nearest: Wel �Foun�dalion—ra Property Line_ 1 SEEPAGE PITS I i Depth Size y r. SUMPS LlDistance to nearest: Well Number DISPOSAL PONDS ID Property Property Line ► 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 J rules and regulations of the San Joaquin Local Health D1'ktrict. Home owner or licensed agent's signature certifies the following: is � rmance of the work for employ any person in such manner as to become subject to workman's ompensat on Iw soof California."Contractor'srhiringch r or sub-cont act�g signature not certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shah employ persons subject to workman's compensa- . tion laws of California." I The applicant u cal' r al fired inspecti s, mplets drawing on reverse side. Signed X CITT Title: Date: f FOR DEPARTMENT USE ONLY Application Accepted by Ok-I- Date Area Pit or Grout Inspection by Date Final Area by Date Additional Comments: t7 w c'�L f� } 7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy M3 -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK a INFO CASH RECEIVED ByHDATE ��----y77PERMIT NO. ♦ EH13-24(REV.tinsj �/� EH 14.28 (LTJ J � 1341)