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y APPLICATION FOR PERMIT _4 SAN JOAQUIN LOCAL HEALTH DISTRICT r' 1601 E. HAZEL T OWAVE., STOCKTON, CA Telephone (209) 466-6781 :�s C7 PERMIT 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. '/ Job Address 7�}' _,_ City%_— PM Owner's Name Ph / one Contractor Address ,au x ` Z 7 License NJA^^77 373 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 _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public Cl Other l l Delta Depth of Grout Seal Type of Grout _ I i Irrigation -`/___Approx. Depth i I stern Surface Seal Installed by Repair Work Done Ue Type of Pump H.P. State Work Done Q Well Destruction - ❑ Well Diameter Sealing Material Itop 50'1 _ I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (7 REPAIR/ADDITION l l DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence_ Commercial _ Other 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. ❑ q Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number ` SUMPS L-i 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 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 pars suc anner as to become subje workman's compensation laws of California Contractor's hiring or sub-contracting signature w certifies the f wing: "I certi that in the of a work for which this permit is issued, I shall employ persons subject to workman's compensa- tion las o alifornia." The appli ant mus all to requir n ns. omple drawing on r9w5kse side. Oe Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by � '�> �" �. DateArea / Pit or Grout Inspection by J Date Final Inspection by Date I 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 CK 4 CASH RECEIVED BY DATE PERMIVNO. + £H 13-24{REV.t i e 51 EH 14-2e fid'