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APPLICATION FOR PER 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 City Lot Size PM Owner's Name ! Address ��9 Phone �I Address �f7 t F� _ License No.�99�� Phone' Contractor . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D FLD. PROP. LINE :11 FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS \ 1 ❑ Industrial Il: ❑ Open Bottom eca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic//Private ❑ Gravel P ❑ Tracy Type of Casing Specifications [1 Public er 171Delta Depth of Grout Seal Type of Grout — i I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair rk Done LlType of Pump a� y H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 I1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 1 I DESTRUCTION (No septic system permitted if public sewer is Lill available within 200 feet.l Installation 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. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Fbundation Property Line \ LEACHING DINE ❑ No. & Length of lines- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PIITS i I Depth Size Number SUMPS IL-1Distance to nearest:' Well Foundation Property Line 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, and 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 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,1 shall employ persons subject to workman's compensa- tion laws of,California." 4The applicanmust call for all required inspections. Complete drawing on reverse side. Signed X 11 Title: Date: — li .FOR DEPARTMENT USE ONLY ._. Application Accepted by Date ,0— — Area N / Pit or GroutInspectionby Date Final Inspection by — Date ( �� Additional Comments: -- ❑ Stk 46676781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE AMOUNT DUE AMOUNT REMIT-TED CA H RECEIVED BY PATE PERMIT'NO. II INFO / +.EH 13-24 4REV.1 i 1;S) �"'] - /0— y EH 14-26 ,/