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I APPLICATION FOR PERMIT `�`� + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t`� 19Qr Telephone (209) 466-6781 St� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ZCj,�(s�CNA��tL., Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w5'rkQorei I described, This application is 1 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. Job AddressCity Lot Size PM k Owner's Name_ �A- �° „ _ r A_dress Phone Contractor Address O 40 G= icense No 3?6_2- Phoneme-' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] SYSTEM REPAIR RN, OTHER L1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11110omestic/Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public 1711 Other ❑ Delta Depth of Grout Seal Type of Grout _ I Irrigation i _ --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done tilt, Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T _� h ype/Mfg •+ Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &_Length of lines _ Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation ,Property Line SEEPAGE PITS l I Depth Size rt Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 Diltrict. 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."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 must cal for all required inspections. Complete drawing on reverse side. Signed X Title: Date: _� �!i��"""' R DEPARTit11ENT USE ONLY a Application Accepted by Date grea Pit or Grout inspection by ate Final Inspection by Le Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 k FEECK { INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH+.EH 13-21(REV.tiKsl 5 +� �fpy� P14lr 2 ,� i1