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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA,Z�ETjON)`XVf yE., STOCKTON, CA r 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. I r r City of Size PM Job Address / Owner's Name tPy Z� xA4io Address Phone ' Contractor, Address Q OC.� License No./4623 23 Phone TYPE OF WELL/PUMP: PUM NEW WELL E5 -,.- Ft.L REPLACEMENT LJDESTRUCTION LI LLATION 0_,-"_' _, SYSTEM REPAIR OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP, LINE FOUNDATION✓ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEO USE TYPE OF WELL PROBLEM AREA N CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a } Type of Casing Specifications ["1 Public ❑ Other Cl Delta., 1.,I Depth of-Grout Seal-" Type of Grout ! I I Irrigation /_Approxi,Depth`i I.Ea�tern Surface SeaLlnstalled by Repair Work Done [per Type of Pum1 H.P. �!`' State Work Done Well Destruction ❑ Well Diameter 4 Sealing Material (top 501 \ Depth : -"'Filler Material (Below 50') -- 1 TYPE OF SEPTIC WORK: NEW INSTALLA710N"1:1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system Per if public sewer is f -1 available within 200 feet.) Installation will serve: Residence—;,Commercial— Other i Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg f�' Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearestF. i Well Foundation Property Line Y- SEEPAGE PITS 11 Depth ''_/Siie _ Number SUMPS L1 Distance to nearest: +' Well\ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and thatlthe work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health DiMrict\ Home owner or licensed a ent'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 perso n such m er as to become subject to workman's compensation to of California." Contractor's hiring or sub contracting signature certifies the fo wing: "I certify at in the perfor ancFoot, wor, for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of alifornia." 10 /f The applic t must c fo quired i n re„��.�1'de. .Date: Signed X` Title: -, -FO EPA'RTMENT USE-ONL-Y- .--�-- Application Accepted by Date Area Pit or Grout II pection by Date Final Inspection by Date Z 1 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 i 4 lFEE AMOUNT DUE AMOUNT REMITTED CK-9T' CASH RECEIVED BY DATE PERMIN0. a, ♦.EH 17.24(qEV.r i w 51 1 EH 14.26 1