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APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 q County with San Joaquin Coun Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin i Local-Health District. 4 Job Address / y City �-" ' f Lot Size PM Owner's Name � r Address 1�8�G N• Phone ` ^/a' Contractor G~ Address ' tJ4icense No. 7t_QIO y�sPhon� TYPE OF WELL PUMP: NEW WELL WELLI-REPLACEMENT.El DESTRUCTION ❑ y� 4 PUMP INSTALLATION'.0 "�SYSTEM REPAIR 13 PA OTHER'0 P ON DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE. FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOtip Lr ❑ Industrial ❑ O0�an Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Q'Gravel Pack pI_TracyE r`" Type of Casirig�' `P '" +�, ; —S-pecificationsR ❑ Public r❑Pthyr ❑ Delta �i Depth of Grout Seal 8c� .� Type of Grout ❑ Irrigation �f0�pprox. Depth ❑ Eastern` Surface Seal Installed by ^ Repair Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 501) d rwrevT- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation wi Residence_ Commercial Other f Number of living units: ber of bedrooms ,r i Character of soil to a depth of 3 feet: Water table depth ° SEPTIC TANK ❑ Type/Mfg : Capacity No. Compartments k. PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Welly Foundation Property Line I i LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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, and rules and regulations of the San Joaquin Local Health .District. Home owner or licensed agent's signaturecertifies 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- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. f Signed Title:. 1�/: .� Date: -*— I FOR DEPARTMENT USE ONLY �</ I /�7 Application Accepted by Date Area I Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 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 RECEIVED BY DATE PERMIT NO. INFO Pf. /CASH /(��/ + EH 1324 1REV.i l a 51 �f /S -�✓" / `F EH 14-28 GGG"'