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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) 0, ' 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 Cou ty Ordinance No.549 for sewage or No. 1862 for Welk/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address IR P leED� p of Size PM AhLoOwner's Name Address Phon r! AddressLG F cense No. 14� Phone Contractor�/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR ❑ fir' OTHER ❑ c - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 Vey FOUNDATION AGRICULTURE WELL ;,OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCjION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ofWell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �* k i Irrigation --Approx. Depth ❑ Eastern s ' I_ Surfac Seal Installed by i Repair Work Done ;❑' Type of Pump_ $Val . ,H'zi p' State Work Done � � t Well Destruction El Well Diameter __ t ,-Sealing Material Itop 501 a Depth + Filler Material tBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EREPAIRIADDITION ❑ DESTRUCTION ❑ (Naiisep iw system tem rented if public sewer is Installation will serve: Residence i °'Commercial— Other Number of living units: Number of bedrooms j Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK ❑!'Type/Mf-1 Capacity_ N artments PKG.. TREATMENT P1rT: ❑ Method of Disposal Distance:to nearest: Well Foundati Property Line LEACHING LINE t ❑ No. & Length of lines Total lengthlsize # FILTER BED ❑ Distance;to nearest: Foundation �" Property Line SEEPAGE PITS j ❑ Depth Size, r Number SUMPS , ❑- -Distance`to nearest. Well ."' Foundation Property Line , t 5 DISPOSAL PONDS ❑ �"'" I I hereby certify that l 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. I 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 rson in such manner as to become subject to workman's compensation laws-of California." Contractor's hiring or sub-contracting signature certifies the o owing: "I certify thatin the perf6r nce of the work for which this permit is issued,I shall employ per subject to workman's compensa tion laws o C lifornia. The applica t I for requ a pecti . Complete drawing on reverse side Title: SJGIit'�' z< 4 U Sig ned — L��`� Y Date: FOR pEPARTMENT USE ONLY .� Application Accepted by Date rea i e Pit or Grout Inspection by Date Final Inspection by Dat I 0 Additional Comments: ❑ Stk 466-6781p ❑ Lodi 369-3621 ElManteca 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 I AMOUNT DUE, AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO 7� CASH + EH 1324 MEV.1/851 '1 i - E14.14-213 ✓✓✓ . I �