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APPLICATIOMFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED My (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 rin 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.. t s } L�1 a% 'f% �'[�S ` �T LL �I U o r Job Address d M rY City of Size PM !!.�N a Owner's Name �riy �'y �eiecddress Phone ' Contractor's Name, r E License No. �1 �I I'� Q �% N� " \ Phone 6 55-21 6 TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/ Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction X TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS AMOUNT REMITTED ❑ Open Bottom r. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack ❑ Tracy f Type of Casing Specifications ❑ Other ❑ Delta `f Depth of Grout Seal Type of Grout __Approx. Depth ❑ Eastern j,J �' }`Surface Seal Installed by V Type of Pump H.P, i € State Work Done 0 Well Diameter ff Sealing Materials (top 501 p. WN F-�^+ M Depth / O O Filler Material (Below 50') 41`10 0 12.. !�J +^0. V 1z.( TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted i available within 200 feet.) ` Installation will serve: Residence I Commercial 1 Otherk••�Al Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ,,_J ,SEPTIC TANK r 01 Type/.Mfg '' ' Capacity No. Compartments _ PKG. TREATMENT PLT: ❑ Method of Disposal — Distance to nearest: Well Foundation Property Line LEACHING LINE FILTER BED ❑ No. & Length of lines Total length/size— H] ength/size0 Distance to nearest: Well ,r. Foundation Property Line A 1 I: . SEEPAGE PITS SUMPS C3.. DISPOSAL PONDS El Depth f Size Number Distance to -nearest:~ .t Well }Foundation Property Line }:. t, if public sewer is k. I hereby certify that I hav6 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." Contractors 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: �FORRTMENT USE ONLY Application Accepted by Date /0-/ Area �J/ Pit or Grout Inspection by Data Final Inspection by Date �V Additional Comments: ot ❑ Stk 466-6781 Lodi 369-3621 ID Manteca 823-7104" .❑ Tracy; 835-6385 Applicant - Return all c pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 96201 c Ma Iry iL + EH 13-24 (REV. 10193 EH 14-29 FEE INFO AMOUNT DUE ! AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. o •a y �K�'. 4 ©��s 4 5 C1 :a F