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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Local Health District. Job Address `+' d City � � Lot Size PM �� Owner's Name Address Phone_. w Contractor o_ erw &97,?f - Address License No. T& Phone v� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ` I FOUNDATION s _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �} L7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I 1 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 50'1 y Depth aterial (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION -PAIR/ DITION l 1 DESTRUCTION o septic system permitted if public sevm is avail ble withi fe k Installation will serve: Resid nce X Commercial— Other �l�$ =a . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: — �x ` Water-table-depth _ SEPTIC TANK TypelMfg d Capacity- U' No. Compartments ., PKG. TREATMENT PLT. ❑ Method of Disp ai Distance to nearest: Wellj v- elation.,_..A -Property Line _ LEACHING LINE ❑ No. &Length of lines W -~"'Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS ❑ 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. 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 workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo110 ' g: "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 Calar iai." The applica t call atl reauL&d ins plata drawing on averse std , Signed X Title: Date: .�� FOR DEPARTMEN SE ONLY Application Accepted by Date S �;�;2 A / it or Grout inspection b ace �yFrinal Inspection b, Date ( '' -Pit 25mments� ❑ Silk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., d(95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO •y�� CASH +.EH t3-24(REV.t/N 51 / v EH 14-28 L o