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} APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � l 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 11 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. Ef I` ff # City �� '�CL6t Size `y(f(PM_ . . Job Address ` Phone Owner's Name Address —� 17 /y!i (/ icense NoP9�5/� s Phon < �`�r i Contractor's Name . TYPE OF WELL/PUMP: NEW WELL WELL REPL-ACEMENT+❑ DESTRUCTION ❑ i PUMP INSTALLATION --SYSTEM-"SYSTEM,REPAIR--Z❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i� SEWER LINES DISPOSAL FLD. PROP. LINE std. �! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSIblic ❑ Industrial �� pen Bottom ❑ Manteca Dia. of Well Excavatio Dia. of WP-Lomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifica❑ Public ❑ Other ❑ Delta Depth of Grout Seal Typ f❑ Irrigation _ -Approx. Depth ❑ astern Surface Seal Installed by •-Repair Work Done ❑ Type of Pump c;H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing-Material (top 50'1Depth Filler Material-(Below 50'1TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ , .DESTRUCTION ❑ (No septic system permiavailable within 200 feet.Installation'hWll serve: Residence_ Commercial_ Other Number ofiliving units: Number of bedrooms o, ��Character of soil to a depth of 3 feet: 4 " ' ater table depth C No. Compartments � SEPTIC TANK ❑ Type/Mfg . + P PKG. TREATMENT PLT. ❑ Method of Disposal I� Distance to nearest: Wel Foundation Property Lone' t LEACHING LTotal lenth/sizeINE ❑ No. & Length Ines g FILTER BED ❑ Distanc nearest: . Well Foundation Property Line II w V, Ts SEEPAGE PITS Depth Size Number +' SUMPS �� Distance to nearest: Well Foundation Property Line i 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. i I 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 became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature_�,4 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-, r tion laws of California." r The applicaT mu all for all required inspections. Co I drawing on reverse side. Signed ii Title: _ Date: E ~ I _ , FOR DEPARTMENT,IJSE ONLY7�, _ b t— V Application Accepted by Date Area k Pit or Grout Inspection'byDate �- Final Inspection byDate Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �� INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT"NO. + EH 53-24(REV.10183ff i //f fir'^ l�f� EH 1428 U k - - -