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APPLICATION FOR PERMIT .fin -Z-0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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 C junty Ordinance N/.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dihreld WO � V�rISLot Size PM Job Address 4vkl Lot)-. 3Q City 1310 Owner's Name QL_.-�� Address Phone �cT Contractor dress_ FCl'l.l� License No.S�� Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Z"C£'ST �b2lU 5 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER }� L) T 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 Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,� I'1 Public n Other Cl Delta Depth of Grout Seal – 1 1 Irrigation —Approx. Depth I 1 Eastern Surface Seal installed by "L"Lq Repair Work Done I3 Type of Pump H,P. State Work Done _ t–,E� fL rt Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material lBelow 501 TYPF OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I 1 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- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 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 county ordinances, state laws, an, 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signsN, 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 compens� tion laws of California." The applicant st call 11 required inspections. Complete drawing on reverse side. Signed X Title: Date: FO PEP RTMENT USE ONLY Application Accepted by Date y rea / Pit or Grout Inspection by _ Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 „f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ♦ EH13.24(REV.I/ns) �/� G (•� EH 14-2fS r