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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Dishict. Job Address • r City Wiz` Lot Size �a�� PM---..-- Owner's Name ' Address �/ PhoneY� - pp /-oSf3 Contractor ` Address —License No. Phone/_-._ dg TYPE OF WELL) UMP: NEW WELL l WELL REPLACEMENT ❑ DESTRUCTION F PUMP INSTALLATION L SYSTEM REPAIR i__) OTHER n 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 U Industrial O Open Bottom Li Manteca Dia. of Well Excavation _ Dia. of Well Casing _ U Dornestic/Private ❑ Gravel Pack . LJ Tracy Type of Casing-. Specifications -1 Public [.I Other !7 Delta Depth of Grout Seal Type of Grout I Irrulalion —.Approx. Depth I I Eastern Surface Seal Installed by ---- Repair Work Done Ll Type of Pump __ H.P. _. .._ ., State Work Done Well Destruction L Well Diameter _ Scaling Material (top 50') Depth _ _. Filler Material (Below 501 TYPE OF SEPTIC WORK: f1EW INST LLATI N r 1 REPAIR/ADDI I (No septic systern permitted if public sewer is t} ON I I DESTRUCTION I available within 200 feet.)' Installation will serve: Residence— Commercial_ 00er Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK O Type/Mfg Capacity_ _ _ No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation _. Property Line LEACHING LINE LI No. & Length of lines _ _ _ Total length/size_ _ Fll TER BED ❑ Distance to nearest: Well-_ Foundation __ Property Line SEEPAGE PITS 1_I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property tine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dstrict. "I Certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: 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 n st call for all required inspec ions. Complete drawing on reverse side. Signed X - � Title: % Date: FOR DEPARTMENT USE ONLY Application Accepted by bot2 Date - _ Area Pit or Grout Inspection by, Date Final In action by Date Additional Comments: ""' 'v tw,( �` rf C Stk 466-6781 O Lodi 369-361 O Manteca -7104 O Tracy 835-&385 / Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO -- . EH 13.24(REV.v/n5) �O O , / EH t4-28