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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� 4 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 �,O 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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weRlpump and the Rules and Regulation made s of the San Joaquin Local Health District. /.S �• ��ki 7—K--Cii!I � cty ��DcKT�ot Size PM Job Address ��G� � t� Phone d a Address Owner's Name / I J,� f Gl/aC' �C �s�5TZ Phon ld'�3�x/.11 Addres License N Contracto DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS ' FOUNDATION AGRICULTURE WELL OTHER WELL r s INTENDED USE TYPE OF WELL �PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑-Open Bottom ❑.Manteca Dia. of Well-Excavation Specifications kType of Casing �r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout ,\\ i ❑ Other Cl Delta _ l f`l Public f Approx. Depth I I Eastern Surface Seal Installed by V, ( I irrigation State Work Done— Repair Work Done Ll Type of Pump H.P. ! Sealing Material Ito.p 50'i Well Destruction ❑ Well Diameter i Depth Filler Material (Below 501 Jo septic system I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDIT�ON l I DESTRUCTION availabe within 200 feet,) if public sewer is 1 Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms xa� Water table depth Character of soil to a depth of 3 feet: f +,r ❑ Type/Mfg Capacity No. Compartments i SEPTIC TANK Method of Disposal PKG. TREATMENT PLT. ❑ I Property Line { Distance to nearest: Well " Foundation ` Total length/size LEACHING LINE ❑ No. & Length of lines property Line FILTER BED EJ Distance to nearest: Well Foundation Size Number SEEPAGE PITS 11 Depth Property Line SUMPS J Distance to nearest: Well Foundation DISPOSAL PONDS ❑ 1 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 l 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 she 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 personfollowiin u certify that s 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 u t call for all req a inspections. Complete drawing on raver t/��w�^ _ Y� Signed X aft, Title: _ (�) — Date: // 2 - FP EPARTMENT USE ONLY O Data ea Application Accepted by 1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 w Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95211 FEE CUNT DUE AMOUNT REMITTED CK CASH RECEIVED By DATE PERMIT'NO. INFO ♦,EH13-241REV.1/w51 04 14.28