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i In APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 4 9 :1'i.. is,Z In., ! the Application is hereby made to the San Joaquin Local Health District for a permiNo 1862 construct for and/or install and the flutes and Ragusa[ono of e anrJoaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. Local Health District. 6 ' City Lot Size PM Job Address >>`` �� , �tom- 11 Phone mes Owner's Na7? Address License No, b2 Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL>q WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM rREPAIR ❑ OTHER ❑ '�� POOP. LINE DISTANCE TO NEAREST: SEPTIC TANK ? `Z) SEWER LINES CO DISPOSAL FLD" _ FOUNDATION , 'Z AGRICULTURE WELL ZkaW—OTHER WELL1W.3XPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS77 ❑ Industrial ❑ Open Bottom +I Manteca Pia. of Well Excavation �� Dia. if Well C'3 Domestic/ Gravel Pack ❑ Tracy Type of Casing Specifications �� Do ('1 Public Cl Other F1 Delta Depth of Grout Sea{ I Type of Grout I I Irrigation —.Approx. Depth l 1 Eastern Surface Sea] Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter -7— Sealing Material (top 511 Depth Filler Material I Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l l DESTRUCTION I I (Nos ptic system hin m rmiieeitted if public sewer is availaInstallation 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. El of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl, 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 applicant rAust ca for all re 'ad ' spections. Complete drawing an reverse sada. " Signed Title: >' L Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit�or Grout Inspection by Date O Final Inspection by �lfY`— - _ Date Additional Comments: ❑,Sik 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED fiY DATE PERMIT-NO, INFO Q �/ wX0/V. � EH 14-2E V�