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APPLICATION FOR PERMIT ( SAN JOAQUIN LOCAL HEALTH DISTRICT J E 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES S YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made in compiiarice with San Joaquin County Ordinance No:49 for sewage or No. 1862 for we@!p ump and the Rules and Regulations of the San Joaquin Local Health District. ��'}(,� ,f �.+ r City ' Lot Size PM Job Address J r��is�Ce &_" Address N Phone Owner's Name �• c License Nol Phone 'Contractor • 4--4wK61,� NE TYPE OF WELL/PUMP: W WELL 13WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER EI (n PUMP INSTALLATION ❑ " - {1 SEWER LINES _��-- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, Dia. of Well Casing ❑ Open Bottom Ll Manteca Dia. of Well Excavation ❑ Industrial Specifications ' T e of Casin ❑ Domestic/Private 171 Gravel Pack ❑Tracy yp g Type of Grout f`1 Public ❑ Other ❑ Delta Depth of Grout Seal t - I I Irrigation _.-Approxi Depth l I Eastern Surface Seal Installed by r ._ State Work Done Repair Work.Done 11 Type of Pump H-P-: _- �` 3 { 1 Well Destruction ❑ Well Diameter Sealing Material Itop 50'i Depth Fiber Material (Below 54'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I.]- REPAIRlADDITION l II DESTRUCT (No;lsepticle syitn m permfeetit ed if public sewer is . . Installation will serve: -Residence— Commercial's Othei - . � Number of living units: Number of bedrooms tWater table depth Character of soil twa'depth of 3 feet: No. Compartments i Capacity SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑. Property Line Distance to nearest: Wellfoundation r ' Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED [I Distance to nearest: Well' Fnunifation Number 1 F SEEPAGE PITS [ I Depth, Size� .. Property Line SUMPS L) Distance to nearest: Well Foundation DISPOSAL PONDS ❑ ` I hereby certify that I have prepared this application and that the work will be done,in accordance with SanJoaquin 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- I tion laws of California." 1 r The applicant t cal o quire in tions. Complet rawing o verse side. r ¢s f Date: �f Title Signed X I FOR DEPARTMENT USE ONLY I ' Date --2 { rea Application Accepted by Date Final Inspection by jlh� to - Pit or Grout Inspection f C/ r E - Additional Comments: L. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 Applicant- Return all copies to: Env CK RECEIVED BY 'k' DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH f INFO `+ EH13-24(REV.1/ EH 14-26 . . j