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�� `r✓P APPLICATION FOR PERMIT ;e t SAN JOAQUIN LOCAL HEALTH DISTRICTD 1601 E. HAZE T ON AVE., STOCKTON, CA _ _Telephone;(209) 466-6781 1PERMIT EXPIRES TYEAR 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. 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. f, City Lot Size PM Job Address f _ Owner's Name Address Phone _� — _ Contractor— ' AA %ddress License No Phanefh —a> TYPE OF WELL/PUMP: NEW WELL FIWELL REPLACEMENT d DESTRUCTION ❑ + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDf L'F D. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIQNS ❑ Industrial ❑ Open Bottom Cl ca Dia. of Well Excavation Dia. of Well Casing ID Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications FI Public ❑ Othe ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation _.Approx.;Depth t I Eastern Surface Seal Installed by - Repair Work Done Type of Pump H.P. State Work Done_ Well Destruc on ❑ Well Diameter Sealing Material Itop 501 . Depth I Filler Material (Below 50,). TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I I DESTRUCTION YINo septic system permitted if public sewer is ,1e, Nyvailable within 200 feet.) Installation will serve: Residence Commercial— Otheri i Number of living units: Number of bedrooms c '. Character of soil to a depth of 3 feet: a Water table depth t SEPTIC TANK ❑ Type/Mig CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line y I LEACHING LINE ❑ No. & Lerigth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Size Number - SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. I shall not employ any per r h nner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the fol; i "I rt y that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- k tion laws of C ifor i .' The applicant a wired inspections. Complete drawing on revers aide. Signed X Title: WJ]Vg,�y(� Date: OR DEPARTMENT USE ONLY � " Application Accepted by" Dat Area. �{ Pit or Grout Inspection by Date Final Inspection by4Date v Additional Comments: I III ❑ Stk 466-6781 ❑ Lodi 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV,1/8 5) C) t EN 1429 �C