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rAPPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 1 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. / o� / � 11 Job Address City Lot Size�o 4 PM ' Owner's Name = Contractor Address 46 License Nol Phone TYPE OF W L/ MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. ofWellExcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other n Delta Depth of Grout Seal Type of Grout _ 1 I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done [ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 DepthFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAI COITION I I DESTRUCTION I I (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. Companments - PKG. TREATMENT PLT. ❑ /�. //yf Method rspgSal Distance to nearest: Well Foundation /(9 Property Line (!!/ LEACHING LINE ❑ No. & Length of lines 44 Total length/size_�G FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth-/• Size Number Ll Distance to nearest: Well Foundation Property Line UMP 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, a rules and regulations of the San Joaquin Local Health D3trict. 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 usor.,all re ad inspections. Complete drawing on verse side. !//!�E/ 7 Signed X F Title: _ Date: ��R DEPARTMENT USE ONLY Application Accepted byDate `- Area-. 6� Pit or Grout Inspection by Dattee/ F al Inspection by Date_L<J13Lsti-'7 Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6185 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 EVRECEIVED BY DATE PEE,,RMIT'NO. EH W4•.EH 1.�IR .r/xsl I // (J J _(�C� �/ -lAO