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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTI ON AVE., STOCKTON, CA Telephone (204) 466-6781 PERMIT EXPIRES 1 YEAR 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.THs 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. , Joh Addre � .1 City Lot Size PM Phone n ylf_3 F Owner's Name a'�` �; fJ CQ'A'— Address � '� PIS �'tf-C.Address. ' 4 Cp License N `�• a Phone Contract` . - 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1Industrial 13Open Bottom ❑ Manteca Dia. of Well Excavation,,- Dia. f Well Casing wli ondmestic/Private El Gravel Pack ❑ Tracy Type of Casing ' - Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r fn ❑ Irrigation --Approx. De tfi ❑ Eastern Surface Seal installed by *_ Repair Work Done ❑ Type of Pump � .� H•P- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic systdhf permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial, Other Number of living units: Number of bedrooms R Character of soil t 1a depth of 3 feet: �^ Water table depth SEPTIC TANK ❑ Type/Mfg' I` Capacity=,#t"f -A No. Compartments —" Disposal PKC. TREATMENT PLT. ❑ Method of Di� I ..... � � 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 SEEPAGE PITS . ❑ Depth t• Size Number fr ' SUMPS D Distance to.nearest: Well Foundation Property Line r 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, 1 shall not I 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:;'('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 C 'orni i The applican ust call.for all required ns s omplete drawing on rse side. r GV Signed t Title: Dat F DEPARTMENT USE ONLY — Application Accepted Date Area Z Pit or Grout Inspection y Date Final Inspection by T � — Dateti �-� 1Ak i Additional Comments: i ❑ Stk 466-6781 i ❑ Lodi 4.369-3621 Cl Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE L AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. k INFO /p f 13- + EH 1324 I REV,7/e 57 'Mc, 14-26 ��