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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "v,D ; tVj 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instl I t k i esc ed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump an Ru n egulations of the San Joaquin Local Health District. Job Address _ City Lot Size PM Owner's Name �N i�.-��G 1�><-�� Address . C)� E Phone -..,. S -0 Contractor Address License No. Phone TYPE OF WELLIPUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial .0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic I Private ❑ Gravel Pack. D Tracy Type of Casing Specifications * Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout —. \� i I Irrigation —.-Approx.,Depth t I Eastern Surface Seal Installed by - V IRepair Work Done ❑ Type of Pump H.P. State Work Done _ f !I Well Destruction ❑ Well Diameter Sealing Material (top 501 { Depth Filler Material.(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 4 I DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ._._._.___.___Number-of-living.units:-- - Number-of bedrooms- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size i 9 �. f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number { SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! 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 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 California The appiic st colt for all requi inspections. Complete drawing on reverse side. ! Signed _ Title: 1 Date: F R DEPARTMENT USE ONLY } Application Accepted by ca,4, Date �� _ Area 1 } Pit or Grout Inspection by hate Final Inspection 1}y � � Date Additional Comments:: & ' tv-yv © Stk 466-6781 ❑ Lodi 3694621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ff Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 �`� f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'nr0. 33 INFO CASH 7 + EH 13.24 MEV-i/H 51 a EH 1428