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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. ,.r Job Address Cit Lot Size PM Owner's Name Address C�'4orgatv��Z�� _ s icense No. —, Phone TYPE OF WELL/PUMP: EW WELL CI WELL REPLACEMENT C1 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS iINTENDED USE ' _'`TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `" Dia. of Well Casing X }omestic/Private ' ID)Gravel Pack L1Tracy Type of Casing Specifications rr M Public 1=I Other F1 Delta Depth of Grout Seal Type of Grout --- I I Irrigation ��=Appfox qpt l I rn $ ice �j§al Installed by_W__ !E' — Repair Work Done D' Type of P��. I State Work Done _ Well Destruction ❑ Well Diamet r Sealing Material )top 50'1 Depth p Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION—[ I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:i Residence_ Commercial— Other ` LA Number of living units: Number of bedrooms Character of soil to a depth 6f'3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 I I Depth Size Number SUMPS 1:1 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 Joaquincounty ordinances, state laws-aiitf 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."Contractor's hiring or sub-contracting signature certifies the following: 1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant t call Mired inspections. Complete drawing on rev, se side. Signed Title: Date: I �FQ�EPA�RT"ENT USE ONL Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Dater Z S (� Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 i❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NOEH 13-24 . * EH 14.zg IREV.1/N5Y -� S//11 t? CtD O