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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED + II Application is hereby ma (Complete in Triplicate) + de to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.made in compliance with San Joaquin County !! Local Health District. / tY Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin C0 3/f � abed. This application n Job Address n ,4 N city ° 1 .. F. Lot S1ze„_f49Wr Bd PM Owner's Name Address =- Contractor -/dr Phone" ess ' ` , TYPE OF WELL/PUMP: icense No �. NEW WELL �-�^- WELL REPLACEMENT ❑ AhBne PUMP INSTALLATION $'— DESTRUCTION LJtai DISTANCE TO NEAREST: SEPTIC TANK J SYSTEM REPAIR ❑ OTHER ❑ -,/—� SEWER LINES ,�� DISPOSAL FLD1 O FOUNDATION � '® AGRICULTURE WELL PROP. LINE L INTENDED USE OTHER WELL PITS/SUMPS` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$ �❑� Industrial pen Bottom �- �'Domestic/Priya#e ❑ Manteca Dia. of Well Excavation i/ ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing ❑ Public ❑ Other Type of Casing ®Bcifications ❑ Delta Depth of Grout Seal ❑ Irrigation --Approx. Dept ❑ sternType of Grout .� Repair Work Done IJ Type of Pump Surface Seal Installed by .. H P .� Well Destruction ❑ Well Diameter State Work Done Sealing Material (top 501) Depth Filler Material (Below 50') U j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i Installation will serve: Residence_ Commercial available within 200 feet.) Other Number of living units: Number of bedrooms x Character of soil to a depth of 3 feet: k r SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ - Capacity 1 No. Compartments Distance to nearest:, Well t 'Method of Disposal Foundation Property Line " f s LEACHING LINE O No. & Length of lines r FILTER BEDTotal length/size Ll Distance to nearest: Well Foundation _rrte' -Propety Line SEEPAGE PITS ❑ Depth f SUMPS Size Number "' r ❑ Distance to nearest: Well �'"'� { DISPOSAL PONDS ❑ I _... _ ._, �_¢ Foundation Property Line i i h I hereby certify that I have prepared this application and that the.work will be done in accordance with San Joaquin county ordinances' laws, and rules and regulations of the San Joaquin Local Health Distr�ct`�'r Home owner or licensed agent's signature certifies the foIiowing: "!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 Jaws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the w6rk for which this er_r i is issued, I shall employ tion laws of California." P p y persons subject to workman's compensa- `The-a.pplican�m call r all required.iris cfons. Compl ing on reverse std�e 1. 4 I" f Signed _ t � Title: Date: •�`/J r FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Ins ctio by t Date Final Inspection by } J Date dditiona C m�781 tk {466-6 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835- Applicant-jReturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k CA+r I ,. - FEE AMOUNT_.DUE� '°AMOUNT. RECEIVED 8Y , °FEE REMITTED-.�.�_ i _, CASK- DATE ---PERMIT=N0. EH 18-24(REV.I/ab) ♦� QS. r ti*'' 4 EH 14-26