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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 EXPIRES,1',YEA-R-FROM•:DATE_I.SS.U-ED__ (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. yp Ali p"` Job Address !/ -7 J�r y 1 __ _ City J Lot Size PM r Owner's Name Address Phone Contractor �. �.- rl�c .� - Address �� .��Cicense No. �& Phane �� TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 1 SYSTEM REPAIR'U """""' """' OTHER-❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ".OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia of Weil Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public F] Other 11 Delta Depth of Grout Seal Type of Grout _ I I Irrigation __-Approx. Depth I I Eastern Surface Seal Installed by 7 Repair Work Done ❑ Type of Pump H,P. State Work Done_ t Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 s r r TYPE OF-SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ICI.--BESTRUCTION 1 ){INo septic system permitted if public sewer is !available within 200 feet.) " (1 Installation will serve: Residence-1--'tommerciai Other F fa Number of living units: .Number�f be oms Character of soil to a depth of 3 feet: Q ` Water table depth SEPTIC TANK ❑l Type/Mfg �,�y. Capacity No. Compartments PKG. TREATMENT PLT. ❑ `" c .. _ s Method of Disposal �; Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines length/size Y FILTER HED ante to nearest: Well ! `Foundation /0 Property Line SEEPAGE PITS I I Depth _Size-^-_ Number SUMPS Distance to nearest: WelltY 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•District.-a " 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 worlFn a 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 of California." The applica st c It r!al equir ins c "on Complete drawing o everse ' Signe Title: Date: U i FOR DEPARTMENT USE ONLY f Application Accepted by f Date Area ` Pit or Grout Inspectio i Date Final Inspection by Date f Additional Comments: ❑ Stk. 466-6781 ❑ Lodi 369-3621. .-.p-Manteca—823-7-104--v--❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE _ INFO AMOUNT �DUE "—' �AMOUMT REMITTED" CASH # #s=RECEIVED BY DDATE�( �(PERMIT'NO- t-EH 13-24 EH 14-26(HEV.t/n s) [�'. iMl `. Y f 1