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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1sy 1601 E.1,H STOCKTON, CASEPn `r 1933 Telephone (209) 466-6781 t PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRO Efi:TAL HEALTH i . (Complete in Triplicate) FERMIT/SERVICES 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 Couhty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin f Local Health District. I Job Address r Cit f Size PM o Owner's Name C * � s AD �` �+C� Phoneme I f L i Contractor Address D L Z License No. V Z'� 7 Phone 6 TYPE OF WELL/PUMP: NEVV WELL ❑ WELL REPLACEMENT ❑ / DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ DISTANCE TO N EJEST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F j "FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE 14tif: TA-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LIiOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Priv ate O Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f n'" her Cl Delta Depth of Grout Seal Type of Grout I i I i Irrigation _Approx.'aDepthc`�ri lI tnastern Surf a Seal Installed by , Repair Work Done Type of Pump — H.P. State Work Done Well Destruction D Well Diameterr Sealing Materia! Stop 501 Depth Filler Material {Below 501 TYPE OF 'SEPTIC WORK 'N EWJINSTALLATION I:I REPAIR/ADDITION,I I DESTRUCTION i I (No septic system permitted if public sewer is ¢ havailable within 200 feet.) Installation will serve11 ResideF1nt a Commercial— Other ` !Number of living unitsL- �_�Number of bedrooms a Character of soil t a depth 303xf4t: Water table depth SEPTIC TANK I ��1 Type/Mfg 1 � % Capacity y No. Compartments 1 PKG. TREATMENT PLT. ❑ �1 r t t y ' Method of Disposal Distance to nearest: Well Foundation Property Line t i LEACHING LINE:. ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance'to nearest: ' Well Foundation Property Line ) l I SEEPAGE PITS I I Depth �I Size _ Number .i ! SUMPS ❑ Distancelto nearest: Well Foundation Property Line DISPOSAL PONDS t ❑ I hereby certify t#at 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 ofd the San Joaquin Local Health District. Home owner or livens n gnat c ertifie the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person' such mann as 'T beco subjec orkman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the#otlow g: "I certify at" the m of o work for which t permit is issued,I shall employ persons subject to workman's compensa tion laws of Cali in The applicant s c or all "uired mple drawing on rev Signed X ✓ Title: Date: t FOR R A Df�PARTIVIENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by r Date Final Inspection by Date •r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 CASH RECEIVED BY DATE PERMIT NO. INFO f +.EH 13-24(REV.r/x 5) , 514 14-28 , .