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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 fdr 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. � r City Lot Size PM Job Address �� Owner's Name �' Y Address 5—T 0 7 A ��it�l Phone Contractor *Address icense No. Phone G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Lff DESTRUCTION FT 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 Dia. of Well Excavation Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M public f 1 Other t Delta Depth of Grout Seal Type of Grout i I Irrigation —.-Approx. Depth I I Eastern Surface Seal installed by - Repair Work Done LJType of Pump H,P. .. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 - n TYPE OF SEPTIC WORK: NEW INSTALLATION IREPAIR available within 200 feet./DDITION l I^ DESTRUCTION l I (No septic system permitted if public sewer is U' � n Installation will serve: Residence_ Commercial Other �J) Number of living units: Number of b d ooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundations Property Line LEACHING LINE ❑ No. & Length of lines !/ Total length/size 0 FILTER BED ❑ Distance to nearest: Well /h 0 Foundation '._ Property Line qe� — ,On SEEPAGE PITS 11 Depth 1(l n X/Size Number V r SUMPS L1 Distance to nearest: Well ._-� Foundation � Property Line POSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will bo done in accordance with San Joaquin county ordinances, slate laws, an 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 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 ca[)for all r q ired inspection . mplete drawing on reverse side. Signed X Title: Date: e�� ,FOR DEPARTMENT USE ONLY Application Accepted by AA Date 0-A Area �O Pit or Grout Inspection byfp Datee -Final Inspection by � �-- Date Additional Comments: " Q C l L-)t ISId, �; 0 LJ k?-o ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO CASH y `X'CJ� �(��•� +.EN13-24(REV.I/H5) ��V EH 14-26