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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Y + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tComplete in Triplicate) I r 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. vAddre3 r Ci Lot Size 'M Job f Owner's Name`s•TAddress • Q n-- Phone Gontrac ddress R<D ,License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE h FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial r ❑ Open Bottom Manteca 46 pia.` Well Excaraliiiri" �� "' '� Dia. of WellasirrgF j 1 Specifications ❑ Domestic'/Private ❑ Gravel Pack ❑ Tracy Type of Casing '� # P , * T e of Gra t t•1 Public >' f Other CY Delta,____�Depth of.Grout Seal___ YP 4 I I irrigation 1 _Approx. Depth l l Eastern Surface Seal Installed by Repair Work Done ❑"•Type of PUMP M H.P- State Work Done Well Destruction ❑� ,Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if publicJsewer is a. ri z., available within-200 feet.) �. �/ t Installation will serve: Residence!1,h Commerciale Other. .+� . I, Number of living units: Number o edrobms Character of soil to a depth—of 3 feet:'!' Water table depth SEPTIC TANK Type/Mfg r Capacity_. No. Compartments Z PKG. TREATMENT PLT. Cl l it / Method of Disposal i Distance to nearest: Well Or 0 Foundation Q Property Line�S e, / LEACHING LINE .No:&-Length of-lines Total length/size f_ FILTER BED`,. ❑ Distance to:nearest: Well . Foundation _��— Property Line '1 �'PAGE PITS �Depth Size _ Number / uSUMPS _% L-1 Distance to nearest: Well Z00r Foundation Property Line t n It DISPOSAL PONDS D -� 3# 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 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 Iaws.of California." The applicant cant mus 11 for aff r 'red in pections. Complete drawing on reverse id Signed X Title: Date f - FOR DEPARTMENT USE ONLY H Application Accepted by Date ` Area It r Grout Inspection by ate final Inspection by Date Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 C7`-Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rs ' } ,FEEO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. a.EH 13-24(REV.t/w 5) �. Q� I , l� I EH 14-25 ss