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APPLICATION FOR PERMIT SAN JOAQUIN 1O.CAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA ' Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED M (Complete in Triplicates 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. - `1�1 tf , - r. - t ' r � , Job Address 6?r/ rt4 C�� City��`! '—� Lot Sizo - PM Owner's Name � � / 'Iss Address F �,�'`[�' Phon �✓ Contract Address �� • /�_ nse /Phone! �4. TYPE OF WELL/PUMNEW WELL O WELL REPLACEMENT ❑ DESTRUCTION E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, -SEWER LINES DISPOSAL-FL-O: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ... I Dia. of Well Casing ❑ Domestic/Private ❑ Gavel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other C,-Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth O Easier' Surface Seal Installed by Repair Work Done ❑ Type of Pump 'H.P:.- k State Work Done i i t Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Fillef MMenal-(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO Wo septic system permitted if public sewer is available within 200 feet. I - Installation will serve: Residence�, Commercial----Other--=-` 9 Number of living units: Number ofrbedrooms l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest Well Foundation Property Line I ! LEACHING LINE ❑ No- & Length.of lilies Total length/size E FILTER BED ❑ Distance to nearest: Well Founda lion Property Line ; SEEPAGE PITS ❑ Depth 4 Y Size Number ,I t l SUMPS ❑ .Distance to nearest: g Well Foundatt ion Property Line DISPOSAL PONDS ❑ i� ► . 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.ceriifies-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 st call for all required inspections. Complete drawing on reverse side. Signed X � Titla: Date: FOR DEPARTMENT USE-ONLY Area Application Accepted by Pit or Grout inspection 'I' Date _ Final Inspection by. Date`S Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy y 835-6385 Applicant- Return all copies tF: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEL DUE AMOUNT REMITTED C s_ RECEIVED BY DATE PER NO. INFO + EH 13-241REV.i/q51 Ll F -�a- EH 14OLV 28 s A� �