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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby 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 wagi Pump and the Rules and Regulations of the Sen Joaquin Local Health District. /ity A 5—/ (�[,4✓IjQL�i�1 Yom/ �p (/, � �t Lal Size Job Address C� / Address Phone Owner's Name lJ Contract ddress License No. Phone TYPE OF WELL/P P: NEW ELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El 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 C1 Industrial ❑Open eottom 11 me Dia.of Well Excavation_ Dia. of Well Cooing ElDomestic/Private ❑ Gravel Peck ❑Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ DeDepth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _ H.p._ State Work Done Well Destruction J-) WellDiameter Sealing Material(top 501 .� Depth Firm Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADOITION❑ DESTRUCTION 11 (No septic system,permitted if pubic sewer is available within 200 feet.) Installation will serve: R idence Commercial_ Other Number of living unaa: Number of bedrooms Character of sol to a depth of 3 feet - ' Water table depth SEPTIC TANK [D Type/Mfg 1 Capacity No. Compartmerrts PKG. TREATMENT PLT.❑ i� Method oo DI Pone, it y� Distance to nearest: •" Well- Foundation L.__ Property LEACHING LINE No. &Length of linea _ Total length/size- FILTER BED ,❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth - Size tynber SUMP ❑ Distance to nearest: Well' Foundation Propertytine TYSPOSALPONDS ❑ 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 oardfies the fallowing:"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."Contremor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit H issued,I shall employ persons subject to workman's compensa- tion laws of California." n The applicant ust c for all r e nspectiors. Comp�ye drawing o side. �_ Signed X- �L./yTty7� ,!a`.(/Jf�J_/"_ 75tlar Date: _ FOR DEPARTMENT USE ONLY App] inion Accepted by _�� Date �i A,re ,DtYSA t I anon by DeW/10:4 �2_ Final frspection bq�T � (� Devi i Additional Comments: ❑ Stk 4088781 ❑ Lodi 3639-3021 ❑ Manteca 873-7104 ❑Tracy 815-6385 Applicant- Retum all copies to: Environmental Health Pemrit/Services,1801 E. Hazeltan Aye., P.O. Box 2", Stk., CA 95201 2 IFEE NTO AMOUNT DUE AMOUNT REMITTED OASH RECEIVED eV GATE PER NO. EH,a�.teEy.,,ee, E2d 11/�— X4003 H 142e