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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., 'STOCKTON, CA { Telephone (209) 466-6781 II PERMIT EXPIRES TYEAR 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 t Local Health District. I 1 Job Address ® �� f ' City Lot Size PM Owner's .�.,� n Q�� p Phone c�� Contractor��1- .d Address 494D `--License No.��/46*2-- PhoneLL7-'�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial E Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing kDomestic/Private El Gravel Pack D Tracy Type of Casing Specifications f` Public Cl Other I f-1 Delta Depth of Grout Seal Type Specifications Grout _ I 1 irrigation —Approx. Depth l I Eastern rface Seal Installed by R pair.Work Done ❑ wType of Pum 1pv/yw�-- - H•P• State Work Done Q -Well-Destruction EJ Wel1 Diameter.• s Sealing Material (top 50'1 i Depth Filler Material [Below 501 �J TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I ] FSTRUCTION I ] iNo septic system permitted itpublicsewer is *" �. available within 200 feet.) y Installation will serve: Residence""4Commercial_ Other a Number of living units~` Number of bedrooms (� j Character of soil to a depth of 3 feet i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I >; Method of Disposal Distance to nearest: Well � Foundation Property Line LEACHING LINE D No. & Length of lines ~ , Total length/size . FILTER BED ❑ Distance to nearest: Well Foundation ` Property Line ! f � SEEPAGE PITS I I Depth Size Number SUMPS L1 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 District. *_ +� V Home owner or licensed agent's signature certifies the following: 111 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 al require�i(4pect�ions. mplete drawing on reverse side. Signed X Title: _ .. _ Date: OR ARTMENT USE ONLY ^� J[/_ Application Accepted by Date ,C + Y Area Pit or Grout Inspection by . Date Final Inspection by 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' CK 0 INFO CASH RECEIVED BY DATEPERH—Z EH 1321 fREV. i y 51 f • . _ �' yU EH 11-28 �/ Q 'f