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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. ,off - Job Address / 27 ,4 City Lot Size PM Owner's Name Address Phone Contractor Address d License No.lee Phone TYPE OF WELL/PUMP: NEW VYELL .© WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLANb` YSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f f I 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 Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑.Delta - --Depth of Grout Seal Type of Grout ❑ Irrigation Depth ❑ Eastern Surface Seal Installed by ��L Repair Work Done ❑ Type of Pump ) H.P. State Work Done EylmyA?XW �i Well Destrction ❑ Well Diameter Sealing Material (top 50'1 Ux Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLAT ON ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is l available within 200 feet.) i Installati on will serve: f,esidence Co merciai_ Other Nimber of living units:_Number of edroams Character of soil to a doth of 3 f�ejetl Water table depth SEP-AC TANK ElType/Mfg CapacityNo. Compartments PKG�TREATMENT PLT. (] ,� r Method of Disposal I.—Distanse-to-nearest: Well `Foundation `�_. Property Line LEACHING�INE ��-No.& Length of lines_ ----- T� `� Jer�gth/,s (� l _ -'+`c ' 1 foundation Property Line FILTE€i BE {] —Distancartat: e11 SEEP GE PITS Q Depth t Size Number SUMP ❑ Distance to nearest: Well Foundation Property Line y DISPO�AL,PONDS ❑ r 1 ? I hereby certify that I have prepared this application and that t0eWqrk wkill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies tti -f--ollowing:"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 E certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laQ of California." The applic int oc I require pt�ons. Complete drawing on r e side. 1 } Signed 4 4/44 Title: Date: 4 OR DEPARTMENT USE ONLY Application Accepted by Date Area S Pit or Gro ft Inspection by Date Final Inspection h Date Additional comments. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 ASH RECEIVED BY DATE PERMIT NO. ' INFO +IEH 13-2A MEV.I/s5) 3s,00 EH 1425