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r APPLICATION FOR PERMIT (� I �Q SAN JOAQUIN LOCAL HEALTH DISTRICT /�'Y' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. � /� V-3 2 2.3 Sr�r//N City �i1r' Lbt Size�"' '�� PM Job Address Phone Owner's Name r!�/°rz� Address Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ !DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS b Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F] Domestic/ of Casing Domestic/Private � Gravel Pack ❑ Tracy 9 Specifications FI Public n Other n Delta Depth of Grout Seal Type of Grout — I I Irrigation �PPr A ox. Depth I I Eastern Surface Seat Installed by i Repair Work Done L3Type of.Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 pth Filler Material (Below 50') TYPE OF SEPTIC WORK: rEW INSTALLATION I I REPAIR/ DITION I I *DESUCTION I I (No septic system permitted if public sewer is av ila a within 200 feet.) Installation will serve: Residence_ Commercial_ OtherJ1 i 1 Number ofMiving units: Number of bedr(5mst - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg010� Capacity 17'� No. Compartments PKG. TREATMENT PLT. ❑ �^ Method of Disposal Distance to nearest: Well 2WZ) /Foundation Property Line ` 1 LEACHING LINE l� No. & Length of lines Tot�l length/size FILTER BED 11 Distance to nearest: Well �oundati4n Property Line EEPAGE T I I Depth Size Number PIi S11AAPfr-"' ❑ Distance to nearest: Well Foundation Property Line DI ❑ I;hereby certify that I have prepared this application and that the work will be done in acyordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health 011trict. Home owner or licensed agent's signature certifies the following: "I certify that in4he perflrmance of the work for vvHiC?7 this permit is issued, I shall not employ any person in such mannef as to become subject to workman's gompensaiion laws of California,`,Contractor's hiring or sub-contracting signature certifies the following:"I certify th4t in the performance of the work for v4hich this Reimit islissued,I shah employ persons subject to workman's compensa- tion laws of California."""- e The:pphct u call for all r quired in ctio . Complete drawing on revefse sideSignd , y� Title: r n.l�!' - -- - FO MIENT U,SE ONLY _ Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 _,`N\` ` FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO . EH1}241REV.ti X5) .. ... EH 14-2e