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x �L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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.543 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. N1 Job Address i City �pPM Lot Size Owner's Name Y Address00 Phone Contractor �2�1 License No,_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �,; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wefl Excavation "V ❑ Domestic/Private ❑ Grave! Pack Dia. of Well Casing v ❑ Tracy Type of Casing ❑ Public ❑ Other Specifications rl Delta Depth of Grout Seal Type of Grout I I irrigation —_Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H p - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUC I INo septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS '❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. q y 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 amp) any person in such manner as to become subject to workman's compensation laws of California." Contrac'tor'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 Calaor a." The applicant mu ail for all equire spections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by —�n s "q 1) x ;( - _ Date O t� U � Area Pit or Grout Inspection by Date Final Inspection by r -2 Date Additional Comments: r( 1 I eA r EJ 466-6781 ❑ Lodi 621 ❑ Manteca 823-7104 Ir ❑ Tracy 835-638 f Applicant - Return all copies to: Environmental Health P rmit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 6�I 91-v wJ�X.� � e f C k- 1- t-'-t_ FEEL [ .t. INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY CASH DATE PERMIT NO. 13-24iREV.1ist51 ff'-5, a 10 EH 14.26