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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ) �e (Complete in,Triplicate) 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 Rules and Regulations of the San Joaquin Local Health District y Job Address 57 w •1 City -j-10 0<71&1lLot Size 1/,V �.� PM Owner's Name 4 •G ;} Address �`c f rk ��' Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEP SEWER LINES DISPOSAL FL❑. PROP. LINE U` FOUNDATION AGRICULTURE WELL OTHER WELL MPS �} INTENDED USE TYPE OF WELL PROBLEM AREA STRUC CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca . 0 cavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications + ❑ Public ❑ Other elta Depth of Grout Seal Type of Grout ❑ Irrigation �ppro epth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ T Pump I H.P. State Work Done Well Destruction Well Diameter a# Sealing Material {top 501 Depth Filler Material {Below 501 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.�k Commercia`I OiheF s -Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No, & Length of lines Total length/size { FILTER SED LJ Distance to nearest: Well Foundation .Property Line I i SEEPAGE PITS ❑ Depth Size Number f SUMPS ❑ Distance to;nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 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."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 cant mu I for I r q 'ed inspections. Complete drawing on reverse side. ) Signed X Title: __ _ Date: •r - ' FOR DEPARTMENT USE ONLY I + ,' 1 �� Application Accepted b a = � Pit or Grout Inspection Date Final Inspection by/ D Data Are ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621�. ❑ teca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE ,- i^ AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT INFO ,l 7 + EH 3-24 RM 1/9e1 ` EH 14-26 O if 3E, - 8s