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APPLICATION FOR PERMIT y° �- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;TON AVE., STOCKTON, CA Telephone (209) 466-6781 RERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) lcation is heieb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is AppiY made in compliance with San Joaquin Co{unty Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District.' , City Lot Size_ PM Job Address 11 r Phone�l w"r / ll Owner's Name [U Address ik3,e-,1 /'�:� i " Address License No/.2373 Phone 69- Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION R SYSTEM REPAIR ❑ OTHER ❑ _ SEWER LINES __ _ DLSPOSAL�FLO. - PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _, $ - PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION ofWellxca SPECIFICATIONS Dia. of Weli Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ` Type of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout M j I ❑ Delta t Depth of Grout Seal Public ❑ Other F t _ I I Irrigation _.Apprgx. Dept i I Eastern Surface Seal Installed by Repair Work Done d Type of Pump H P State Work Done Well Destruction EDWell Diameter Sealing Material flop 501 f, + Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {.I REPAIRIADDlTION 1.1 DESTRUCTION {'I availabet'wi within feet.ted if public sewer is ) i1'f, Installation will serve: Residence Commercial Othet• Number of living units: Number of bedrooms Ii ,;fi Water table depth Character of soil to a depth of 3 feat: Capacity No. Compartments '• t SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines s Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ -,. - — Number SEEPAGE PITS l 1 Depth Size = _ Sl1MP5 - - Cl- Distarice to nearest.- I Well Foundation' � r ProperWLinw . .. .: i a ` DISPOSAL PONDS C A i t l -.. _ I hereby certify that i have prepared this aprplication and,�that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District.i Home owner or licensed agent's signature certifies,theJ Mowing: "! certify that in the performance of the work for which this permit is issued, I shall not signature employ any person in such manner as to becomesubjecvto workman's compensation laws of California." Contractor's shin or to workman's-contracting certifies the following:"I certify that in the perfoimailce of the w3 rk for which this permit is issued,I shall employ pesubject tion laws of California." 1 The applica t ust call for all r uired inspecti S. Complete drawing on reverse side. Date: Signed X C4itle: i FOR DEPARTMENT USE ONLY k �}Q$. -� � \ r� 1 j Area Application Accepted by Date IDate Final Inspection by Date �� Pit or Grout Inspection Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT'NO. I INFO AMOUNT DUE AMOUNT REMITTED CASH r EH 13-24 MEV.5 i H 51 -- I EH 14-2e