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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 'A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) LL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des qd. �p'13ion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the R"wMAgI( n Joaquin Local Health District. �ERMS I t 1CY Job Address. ,r�?' d_ / ✓ ,l�/r City Lot Size PM Owner's Name /l/i=� � Address -�O/-2( r Phoner�-� Contrattor .a Address z c ! License No.�Fft,/ Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION K1_ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D SPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __._ Approx. Dep i I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump IN4___ H.P. .- �1 - X_.._._ State Work Done Well Destruction 1--1 Well Diameter ,,Aa Sealing Material Itop 50'1 OF Depth �� / , Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial 1 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 Cl No. & Length of lines Total length/size rel FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number 51 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS f 1 It 9 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, an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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 fy 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 applicant must c If d ' ctions. Complete drawing on reverse side. Signed X Title: Date: C FOR DEPARTMENT USE ONLY t� Application Accepted by Date 1 A V1 Area Pit or Grout Inspection Date Final Inspection by 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.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT'NO. . EH 1324(REV.s i x 5) EH 11.26 C, �,� ]