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�IA3 r v APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE. T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED i (Complete in Triplicate) IJoaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the Sari macre 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 0 0� C't 'Cot Size PM Job Address y OOUNT DUE AMOUNT REMITTED V, dress 30U �✓ �d1.c�'V�` "'�'` hone RECEIVED BY DATE Owner's Name Contractor Address G U License NQ/k, 2J-2-1— Phone TYPE OF WELL/PUMP: INEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 06 SEWER LINES SSD DISPOSAL FLD. PROP. LINE FOUNDATION �� AGRICULTURE WELL _6" OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v\f EIIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion 8 Dia. of Well Casing X Domestic/ Private X Gravel Pack ❑ Tracy Type of Casing - r Specifications i'1 Public [I Other f ! Delta Depth of Grout Sent Type of Grout -" I I Irrigation , -.App�ox Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H, P. State Work Done Well Destruction ❑, Well Diameter Sealing Material {top 50'i Depth _.. Puler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I.Z REPAIR/ADDITION E 1, DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence — Commercial — Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal IRN f Distance to nearest: Well Foundation Property Line [ I , I LEACHING LINE ❑ No. 8i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS { 1 Depth I Number SUMPS _Size ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ C 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." Contractors 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 applicant oust 11 for 9y,06luired in ctions. Complete, jdrawing reverse side. Signed X r`�Title: Date: r EPARTMENT USE ONLY Application Accepted by v Date " i- v - Area Pit or Grout inspection by Date/--.�`Final Inspection by /%?tea Date 2-1 Additional Comments: f �— ❑ 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 1 + EH 13-24 (REV, i i x 51 - EH 14-26 + FEE INFO OOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. j� ' /0`v -W-11" J