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APPLICATION FOR PERMIT ; , SAN JOAQUIN LOCAL HEALTH DISTRICT tF� 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466=6781 PERMIT EXPIRES 1 YEAR FROM' DATE ISSUED'" " 1 (Complete in Trip licke) 1 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 Ryles and Regulations of the San Joaquin "Local Health District. �/�� /� '.:1 fir• ..� , . Job Address !;i r/t��1� ;�/ City Lot Size PM -Owner's Name Address - A�Z .: I Phone / ! Contractor / 5 Address �J License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ . DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4- - OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sealr11 Type of Grout ❑ Irrigation _-4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing.Material (top 50') "t Depth Filler Material (Below 50') V r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-7— Commercial Other v I 4 Number of living units:�tl Number�of bedrooms ryy Character of soil to a depth of 3 feet: Water table depth d_0 SEPTIC TANK V}- Type/Mfg" i'` Capacity�i�� No. Compartments t PKG. TREATMENT PLT. F1I. Y"r` p Method of Disposal-' a Distance to nearest: Well'�Q¢"Foundation_ fProperty Line ti `j r LEACHING LINE V1 No.-& Length of lines "� Total length/size : x, -FILTER BED ❑ Distance to nearest: - Well `S Foundation Property Line i SEEPAGE PITS .DepthSize Number A , -_SUMPS ��.,� w. 'L Distance to nearest: Well es Foundation Property Line DISPOSAL PONDS � � � �� , I hereby certify that'l have prepared tNiis application and that the-work will be done in accordance With San Joaquin county ordinances, siaate laws, d f 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 laws of California." The applican cal r all! uir d 1 s ": pections. Complete drawing on reverspAide. f Signed LTitle: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �°Are;_ Pit or Grout Inspection by Date Final Inspection byRDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 `• ,., Applicant- Return all copies to: Environmental Health Permit/Services 1601 Hazelton Ave., P.O. Box 2009, 5;k., CA 95201 4 FEE AMOUNT DUE, AMOUNT REMITTED INFO t CASHt RECEIVED BY y DATE PERMIT"N0. } +EH 13-24(H EV. �'-'�• EH 1428 �� />/�..5 �S•S ��03 i 3 b 9