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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 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. 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. .. �/3 t� �` City/ Lot Size PM Joh Address Owner's NameW� ,luz Address — �^ Q UJs Contract4;z; Ad License,No. Phone TYPE OF WELL/PUNT NEW WELL F1 WELL REPLACEMENT ❑ DESTRUCTION ')�, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK/_" S DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 17Gravel Pack L3Tracy Type of Casing Specifications ('1 Public H Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYP OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet.) Installation ill serve: Residence— Commercial— Other r Number of livin its: Number of bedrooms Character of soil to a th of 3 feet: _ Water table depth SEPTIC TANK 11 pe/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to arest: Well Foundation - Property Line - t k" ✓ t LEACHING LINE ❑ No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size umber Y r SUMPS Ll Distance to nearest: Well Foundation erty 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. <1 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 laws of California." The appli ant must call f re ire 'nspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY eAz� Application Accepted by ` ��+ _ Date 'Z' a Area Pit or Grout Inspection byDate FirI I Inspection by Date C "� I Additional Comments: cel £� � .Y ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 N0. INFO +.EH 13-24(REV.i/n5Y �� EH t4-28 J .q