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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Q ,City �` '/ �4ize PM Owner's Name l .�� f � % 22 0 _ Phone l Contractor's Name4' )f , No. o4 4y ��^ Phone A� ( l TYPE OF WELL/PUMP: - NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION+�� SYSTEM REPAIR ❑ OTHER.❑ DISTANCE TO NEAREST: SEPTIC TANK It!;EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Vt�1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ' ❑� Industrial ; � n Bottom ❑ Manteca Dia. of Well Excavation f f Dia. of Well Casing Li�Domestic/Private ' ❑ Gravel Pack ❑ Tracy Type of Casing�.��tP-[� Specifications ❑ Public -❑ Other El Delta Depth of Grout Seal - Type of Gro ❑ Irrigation— �'"`��pprox-Dept ❑ tern Surfa�y eal 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ' f available within 200 feet.► Installation will serve: Residence_ Commercial Other — r 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. ❑ sf Method of Disposal }� f Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ' ❑ No. ✓� Length of lines Total length/size FILTER BED ❑. Distance to nearest: Well Foundation r Property Line i SEEPAGE PITS ❑ Depth Size f 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, 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."Contractors 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 applicant mu II for all required inspections. Complet rawing on reverse side. Signed Title: Date FOR DEPA USE ONLY Application Accepted by Date `^ a E" Pit or Grout Inspection by � Zo '^� Date Final Inspection by � � _ Date Additional Comments: �% y *-�-r� �O — e✓C�L�� %�1G�� O-,r/�(,�, ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-t3Mf Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 R � FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. r EH 13-24 lkEv.101831 Q�7 p�y�, %rr L� *t � �'c� q^ �b>� EH 14-28 U <S 3�'4 d" g q �'