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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 18W for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address � ® 11 [�1J City - Lot Size PM Owner's Nam Address Par UL_hAU4JL,_ Phone fA Ir T, Contractor Address icense No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR �[,, OTHER G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '6ISPOSAL FLD. PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIACATIONS V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation h0k[FLDomestic/Private IDGravel Pack -- Dia. of Well Cgsing ❑ Tracy T�pe of Casing Specifications { r f El Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation Type of Grouts _meq :y < pprox. Depth 'Eastern Surface Seal Installed by Repair Work Done Ilk Type of Pump y,p f ! - t S ate Work Done Well Destruction Q Wel! Diameter Sealing Material (top 501 e- "` 1' Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence— Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .? SEPTIC TANK Water table depth ❑ Type/Mfg Capacity-� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No, & Length of lines F Total length/size FILTER BED ❑� Distance to nearest: Well T Foundation ` Property Line SEEPAGE PITS ❑ Depth Size SUMPS Number ❑ 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 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 ys compensa tion laws of California." The applicant m t ca f 21 required inspections. Complete drawing vn reverse side. Signed Title: ��yy � .'-s 7� Date: FOR DEPARTMENT USE ONLY r ,,' .- ` -.• Application Accepf y /F� Date " Area " �� Q cr •Y+ y Pit or Grout Inspeby Date Final Inspection by ' "_Date Additional Comments: ❑ 5tk 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 _W FEE AMOUNT DUE A1� 5, REMITTED INFO C K RECEIVED BY DATE PERMiT'NO. + EH 13-24[REV.t/s5! EH 14-26 . O