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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 'Q PERMIT EXPIRES TYEAR FROM DATE ISSUED f (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. T,+ Job Address G I Q/!/ City Lot Size PM 164 Jo r SZCl<f-?w Si-- PhonevC �� Owner's Name E- Ad— Address Contractor !! Address License No. Phone_ YPE OF WELL/PUMP: 'NEW WELL:❑'e WELL REPLACEMENT ❑ DESTRUCTION ❑ J�. PUM INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ElManteca F Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack },� ❑ Tracy t Type of Casing Specifications ("1 Public Ll Other ❑ Delta 1 Depth of Grout Seal Type of Grout I Irrigation .Approx. Depth I 1 Eastern• Surface Seal Installed,by _ h I" r Repair Work Done ❑ Type of Pump �' H.P, State Work Done t Well Destruction LlWell Diameter Sealing Material Stop 501 r kDepth" Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION [I DESTRUCTION l I INo septic system permitted if public sewer is 0 1 available_ within 200 feet.) ' Installation will serve: Reside ii ce_ Commercial Other y Number of loving units: _I Number of bedrooms Character of soil to a depth of,3 feet: Water table depth f SEPTIC TANK Ll Type/Mfg Capacity No. Compartments > PKG. TREATMENT PLT. ❑ If '; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size, FILTER BED ❑ DItance to nearest: Well Foundation Property Line r SEEPAGE PITS l I D II€pth Size _ Number O SUMPS CI Distance to nearest: Well Foundation Property Line ? DISPOSAL PONDS ❑ ��- I hereby certify that I have prepafred-this-application and that the-work will-be done in accordance-with-San—Joaquin—county-ordinances,-state laws,,-an rules and regulations of the Sari:�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 sIt call far all rd�uired ' do ns. mp to drawing on reverse side wd Signed Xj) �1� sl Tit le: Date: _!?r41 1l FOR DEPARTMENT USE ONLY 3 k Application Accepted by Date ~ .� Area Pit or Grout Inspection by Date f=inal Inspection by Date Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi II 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 \� t -Ic '"FEE ANIOC7NT Dt]E' — AIAOl NT'R'EMITfED� 'RECEIVED BY DATE PERMIT'NO. INFO 711\,♦-EH 13-241REV.iiN51 `J � r lz� e:rl EH 14-28 'i 3 - ��..