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" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,_TON AVE., STOCKTON, CA Telephone (209) 466-6781 V PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 2 2 189 (Complete in Triplicate) ENVIRONME�NTAL}Ml� EALTH�vvlcation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 7�0 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weNlpump and the Rules and Regulations o �application the San Joaquin Local Health District. Job Address City Lot Size PM ! _ �4 y Owner's Name �. , Address Phone c� � Gontracto AddresslW `�t-' Lice se No. Phone TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT ❑ DESTRUCTION C] PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing Ll Industrial L1 Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications Domestic/Private L] Gravel Pack ❑ Tracy YP g Type of Grout — M Public Cl Other Cl Delta Depth of Grout Seal I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by r� e of Pum H.P. State Work Done Repair Work Done Yt` Type p Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I I a o septic systeshin m permitted if public sewer is Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: C SEPTIC TANK ❑ Type/Mfg apacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line - LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0s tate 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 Di§trict. 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 applicant mu for all require inspect s. Complete drawing on verse side. sl~ .,.. Signed X Title: Date: FOR DEPARTMENT USE ONLY 3/ Date Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ava., P.O. Box 2009, Stk., CA 95201 FEELCK RECEIVED BY DATE PERMIT'NO. INFO AMOUUNNT DUE AMOUNT REMITTED CASH [�]^ + EH 13-241REV.1/H 51 3_51 \ C, ��Z� EH 14-28