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APPLICATION FOR PERMIT// SAN JOAQUIN LOCAL HEALTH D TRICT `P� 1601 E. HAZELTON AVE., STOCKTON, CA ' U1' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) Application is heeeby 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 J /027 3 "' � City Loo Size M � � I / 1 S Zo Owner's'Name L� ddress Phone Contractor0 L'Q mipr s License No Phone TYPE OF WELL/PUMP: NEW WELL @� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RIEPAIR ❑ �OT+H�ER�� ❑ DISTANCE TO NEAREST: SEPTIC TANK [[ SEWER LINES 16L) . -_-- DISPOSAL FLD.��0T PROP. LINE f FOUNDATION AGRICULTURE WELL �THER WELL P1T5/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S ❑ Industrial fl Open Bottom ❑ Manteca Dia, of Well Excavation-- _ Dia. of Well Casing LzY6omestic/Private vel Pack ❑ Tracy Type of Casing � Specifications =; _ I'1 Public ❑ Other Cl Delta Depth of Grout-Seal.. Type of Grout —t 1 Irrigation Approx. Depth l I Eastern Surface Seal installed by 76 Repair Work Done L7 Type of Pump �.1:N-.?. State Work Done r I V Weil Destruction ❑ Well Diameter Sealing Material Itop 501 Depth "�Filler Material I Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1"1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is41, �[ f available within 200 feet.) Y(vi Installation will serve: Residence_ Commercial=" Other s Number of living units: Number-o1-bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg } Capacity No. Compartments PKG. TREATMENT PLT" ❑ �� _ W i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line 0 SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! 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." Contractors 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 fficall for all re fired inspqcVons. Compile drawing on reverses�idle. Signed Title: �F'ry Date: TZ 0 FOR DEPARTMENT USE ONLY Application Accepted by Date A Area Pit or Grout Inspection by D Z6 final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CI Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 R-...,- FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY LL DATE PERMIT'NO. INFO + EH 13-21[HEV.i i n s1 06 EH 14-26