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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (� t 1601 E. HAZEL E ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUD (Complete in Triplicate) NUB 5 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t MATOWh"Topplication WE the San Joaquin Local Health District. VER Job Address LJ -� City Lot Size PM t Owner's Namrr - Address w . 22�Phone Contractor -- AddressNy_ ��vSL ,4"� icense NffF��6� fone� f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing e Xpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \, M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I i 1 Irrigation -Approx. Depth Eastern Surface Seal Installed by _. r Repair Work Done ❑ Type of Pump H.P� State Work Done- Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ( TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR'lADDITION l 1 DESTRUCTION i I (No septic system permitted if public sewer is r' available within 200 feet.) Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth It SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments lQ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well y Foundation -.Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ' Property Line 1 SEEPAGE PITS 11 Depth Size _ _'Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q �'- F 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 Di§trict_ _ i Home owner or licensed agent's signature c`erfifies 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 subcontracting 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 appli 11 for all required i pections. Complete drawing on reverse side. Sign Title: Date: `' FOR DEP TMENT USE ONLY Application Accepted by Date Area ?-/j 4y 4y Pit or Grout Inspection by Date Final Inspection by Date / ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l +. ) 3 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ..Ell 13.24(REV.t/N5) QCf 10U O EH 14-25 �+