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r) APPLICA ION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,'ti.- sr 1601 E. HAZE T ON AVE„ STOCKTON, CA '• Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'• } ";:� (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein,describedi EThis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and RCio egulans cf the San Joaquin Local Health District. Job Address City Lot Size PM Tv Owner's Name Lk L6 Address i' Phone Contractor Address License No Phone TYPE OF WELL/PUMP: NEW WELL ❑` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-fir 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing PyDomestic/Private C1 Gravel Pack ❑ Tracy Type of Casing I 7` 9 Specifications Fl Public' (=1 Other F1 Delta Depth of Grout Seal Type of Grout f I Irrigation �-Approx. Depth t I Eastern Su ace Seal Installed by _ Repair Work Dane Type of Pump . - H.P: Z State Work Done. u Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 _ S� TYPE OF SEPTIC WORK: NEW INSTALLATION [:) REPAIRIADDITION I I DESTRUCTION Id (No septic system permitted if public sewer is G available within 200 feet-) Installation will serve: Residence-__ Commercial w Other `fit Number of living units: Number of bedrooms N 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 tine LEACHING LINE D No. & Length of lines Total lengfh/size FILTER BED ❑ Distance to nearest: Well Foundation Ptoperty Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "1 certify that in the performance of the work for which this permit is issued, l-.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 app- st call for all requiredrawing on rave a side. Signed X �ispec�fio . om to Title: Date: TMENT USE ONLY f Application Accepted byDate ' Area 2/ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 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 CK CASH RECEIVED BY DATE PERMIT'NO. -r.4! +,EH 13-24 iREV.I/n 5t �.(�(� /_ EH 14-28 ✓✓ [2 fp ✓1