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{ f 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 F � � (C0MPIatle i T 'p lcat ) E Application is hereby 1natlb�tL o2he SarSJoa Loca�NleltTtii DistraE'tfC�r 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. *W r"4 47 JY- Job,lAddress {. /+_ I �r Cr�C Yrd 1= ' &L�_ City _ Lot Size ; Owner's Name - Address !� Phone Contractor's Name ! License No. TYPE OF WELL/PUMP: NEW WELL ❑ Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR El DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES — DISPOSAL FLD. PROP. LINE FOUNDATION 'AGRICULTURE WELL OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �}.i ❑ Industria! ❑ Open Bottom ❑ Man face o\ 'I Dia, of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac , {� Public Y Type of Casing Specifications ❑ Other ❑ Delta Depth of Grout Seal Type of Grout FO Irrigation .`Approx. Depth ❑ Eastern Surface Seal Installed by l Repair Work Done ❑ Type of Pump IJ F k H'P' State Work Done Well Destruction ❑ Wel! Diameter Sealing Material {top 50') Depth Filler Material (Below 50') TYPEOFSEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic System Y permitted if public sewer is Installation will serve: Residence avail le within 200 feet.] Commercial_ Other Fl� Number of living units: Number of be rooms ! Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth c�a Capacity € 4 �PKG.,ITREATMENT PLT. ❑ `k No. Compartments y / Method of Disppsal Distance to nearest: Well Foundation1 Property Line ar7 [LEACHING LINE No. & Length of lines -- FILTER BED ora! length/size ❑ Distance to nearest: Wel! Foundation �— Property Line {SEEPAGE PITS ❑ Depth SUSize „ MPS DiNumber ❑ stance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line i{ {—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 I� 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 performence of the work for which this permit is issued, I shall not F 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- rtion laws of California." " _,The applicant ust f all rel inspections C c plate drawing on verse side, Signed, Title: Date: FOR PARTMENT USE ONLY Application Accepted by Date /rea ] Pit or Grout Inspection by DateFinal Inspection by ! Date -Additional Comments: , c CcL Z ❑ Stk . 466-6781 ❑ Lodi .369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Flkpplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, StIl CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE :Ml 'NO. H --u 1Rsv.101631 S !10 .