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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 1 ON AVE., STOCKTON, CA Telephone (209) 66-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED rl (Complete in Triplicate) Application is hereby made to the San Joaquin Local Healt ' istrict for a permit to construct and/or install tKutes n described.This application is made in compliance with San Joaquin County Ordinance�o,549 for sewage or No. 1862 for well/pump and tRe ulations o the Sin Joaquin Local Health District. `� erQ�rJob Address ALA�[� �/r �� f`�';' City LotSize vr v— Pill Owner's Name Address 7 3 Phone Contractor's Name Wd License No. ( ST Phone 3 7�4 130 TYPE OF WELL/PUMP: ; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j ,,PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER 11DISTANCE TO NEARE�,SEPTIC TANK I'iZ SEWER LINES DISPOSAL FLD. /30 PROP. LINE1 / FOUNDATION /Z S~` AGRICULTURE WELL s OTHER WELL—a-0 PITS/SUMPS �s�g INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7iCbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __--Approx. Depth ❑ Eastern Surface Seal Installed by + ) Repair Work Done ❑ Type of Pump H.P. State Work Done d4 Well Destruction ❑ Well Diameter Sealing Material (top 501 S Depth Filler Material (Below 501 y TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 00 `L- available within-200 feet.) { Installation will serve: Residence— `-- Commercial_ Other z Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Wate table depth SEPTIC TANK ❑ Type/Mfg ----~–Capacity No. Compartments 11 PKG. TREATMENT PLT. ❑ ' ^Method of Disposal ' d Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest: Well Foundation tw Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line s DISPOSAL PONDS ❑ f I he certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat® aws, 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- '3 tion laws of Califo ia." The applicant uir inspection late drawing on reverse side. Signed Title: ��//�1 Date: s OR DEPARTMENT USE ONLY -�'�� / Application Accepted by Date Area Pit or Grout Inspection by Date Fi al Inspection by /` C -"I Date sr1 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 Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. +.EN 1324(REV.107831 3. �C, 'EH 1426