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APPLICATION FOR !PERMIT SAM JOA aU14°,LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE.; -STOCKTON, CA Telepklphe (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED >T (Complete in Triplicate) k1 i s 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 corripliance 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. , l Job Address 4 ` ' i'i : l City -,Lot Size PM Owner's Name sx 1 1. 1".-Address .I I 4 ' I .i t'� Phone i Contractor :1 c. L• 1 _ _-Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION — AGRICULTURE WELL - OTHER WELL - PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial Cl Open Bottorh ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5 t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V1 Public f71 Other 11 Delta Depth of Grout Seal Type of Grout i I Irrigation _-Approx. Depth I I Eastern Surface Seal Installed by —_ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth ( Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION 1 ftlo septic system permitted if public sewer is f:Pt available within 200 feet.! installation tivell serve: Residence= Commercial_ Other Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LiNE Ll No. 8 Lengih of lines Total length/size ` FILTER BED ❑ bisttince"io nearest: Well Foundation Property Line SEEPAGE PITS I 1 depth I Size Number SUMPS Cl Distance to dearest: 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 this San JoBgdin Local Health District. Home owner or licensed agent's sigriiifure certifies the following: "I certify that in thea performance of the work fot which this permit is issued, I shalt ott� employ any peirgori iii such manner at:tai become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that In the pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." { t! The applicant must call for till Zegtj04d inspection§. Complete drawing on reverse side. Signed X( I =';,`1 � t r, Titlei ti-s • : r .t Date: 1.. I FD"OARTMENT USE ONLY Application Accepted by OD U,,, :h"-ref _ Data Area s Pit or Grout Inspection by Date Final Inspection by _ Date Additional Commenter %y ♦ .� „_„„_ •,_„� ❑ Stk 466-6781 0 Lodi 369-3821 ❑ Manteca 823-71114 O'Tracy 835-6385 Applicant - Return all copies io: Erivironmi ntal Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FLEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y PATE PERMI7'N0: . EH 132/(REv.i i n 5) EH 14-2d i