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I APPLICATION FOR PERMIT SAN JOAQUIN -LOCAL-HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (Complete in Triplicate) ` Application is hepeby 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. 70 7 Job Address City Lot Size PM Owner's Name /'T Address Phone e Contractor Address Jed, � License No.02 2�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPA]R'❑ OTHER ❑ '" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '❑ Domestic/Private i❑ Gravel Pack ❑ Tracy Type of Casing Specifications t 1-1 Public Cl Other Cl Delta Depth of Grout Sea] Type of Grout J' I I Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Wel( Diameter Sealing Material (top 50') Depth Filler Material (Below 501 �J _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence`� Commercial— Other r - Number of living units: Number of bedrooms 3. Character of soil to a depth of 3 feet- Z? Water table depth t SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments- ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ✓- Foundation �_ Property Line f D 4 LEACHING LONE ❑ No. & Length of:lines _ Total length/size ' FILTER BED LJDistance to nearest: Wel!_Q ui Foundation__v?_v7 Property Line _ 4/ SEEPAGE PITS I'1 Depth Size "' Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t' 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,!shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on rave side. f Signed Title: Date: OR D, ARTM _NT U E ONLY , r 9 Application Accepted by ` Date "� Area Ie Pit or Grout Inspection by Date Final Inspection by Date�� Additional Comments: I ❑ 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 95201FEE ? «., INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. 4 ` + EH 13-24.iREV.v/x 5) , EH t4-26 �/"1 T p ,