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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON 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 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. Job Address J 7� �� � C�� Lot Sire., jS ! PM Owner's Name Address 340 0 SI: 6p,�,z -c9 NT $ r/ Phone l(9. ) —c 5,-3p i Contractor Address TYPE OF WELL/PUMP: License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ` DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ �} I SEWE INES POSAL FLD. PROP. LINE FOUNDATION AGRICUL E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO ST TION SPECIFICATIONS ff ❑ Industrial ❑ Open Bottom ❑ Manteca Di o Well Excavation Dia, of Well Casing ❑ Domestic/Private C2 Gravel Pack ❑ Tracy ❑ Public YPe of sing Specifications ❑ Other ❑ Delta Depth of G ut Seal ' ❑ Irrigation --Approx. Depth ❑ Easte Type of Grout F Repair Work Dane ❑ T - - - - Surface Seal I tolled by ` Type of Pump H.P, r Well Destruction ❑ Well Diameter State Work Done_ I Sealing Material (top 50') '----Depth--i_..__ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ -DESTRLICTIO ,(No septic system permitted if public sewer is Installation will serve: Residence Co mmercial Other available within 200 feet.) i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity PKG. TREATMENT PLT. ❑ �. � No. Compartments. Method of Disposal Distance to nearest: Well .Foundation r 4 f Property Line LEACHING LINE ❑ No. & Length of lines t FILTER BEDTotal length/size Distance to.nearest: Well FoundationProperty Line SEEPAGE PITS ❑ Depth Size - rt SUMPS -„W` ” Number a ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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. 41 '% Home owner or licensed agent's signature certifies the following: "I certify'that in the performance of the work for which this mit is issued,employ any person in such manner as to become subject to workman's-compensation laws of California."Contractor's hiring or b-cont actinglssha ignatu et 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 tion laws of California." compensa- tion f pli nt mu call r equired inspections. Complete drawing on reverse side. Signed X Title: — Date: 1 FOR RT�NT ONLY � s Application Accepted by fDate A _�� i rea Pit or Grout Inspection by Date � 3-� Final Inspection by Dates # Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Mante 7104 p Tracy 8355_6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK } INFO RECEIVED BY DATE PERMITNO. + EH 13-24(REV.5/857 U� {{ EH 14-25 �� w / '