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I s APPLUCAT,UN FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA t Telephone (209)466-6781 ]PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' It 1 (Complete in Triplicate) Application is heteby 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. A, Joh Address IIIA `" '/ �� - .__ __ City� Lot Size PM Owner's Name rr r aC Address Phone Contractor7ddress7 < License No. �fS4�Z Phone ~ ��t TYPE OF WELL/PUMP:. . NEW WELL JW WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER )( JA W, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �O � ❑ Domestic/Private VGravel Pack 0 Tracy Type of Casing S09 ZZO nPIG Specifications [IPublic 11 Other 'dF1Delta Depth of Grout Seal r`tJ Type of Grout I I Irrigation _Approx. Depth I I Eastern Y Surface Seal Installed by , S _ Repair Work Done" ❑ Type of H.P.Pump State Work Done _ Welt Destruction ❑ Well Diameter Sealing Material /top 501 Depth Filler Material {Below 501 ; TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION IJ DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) i 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"4"" Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal i Distance to nearest: Well Foundation Property Line . A LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth i l Size Number .E 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." 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 parsons subject to workman's compensa- tion laws of California." The appli nt ust ca for all req!uW inspections. Complete drawing on reverse side. Signed P Title: Date: r 2e4t, P 7. FOR DEPARTMENT USE ONLY Application Accepted by Date 00 Area Pit or Grout Inspection by Date .Final Inspection by t Date� � Additional Comments: __ ! " 6 Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 �f Applicant - Return all copies to: Enviro I ental Health Permit/Services 16011 E. Hazelton Ave. P.O. Box 2 Stk., CA 95201 1 IAIrI S J. o n op k mV r, 5� will// �. C./7 al c� FEE INFO AMOUNT DUE AMOUNT REMITTED ASH 10 RECEIVED BY DATE PERMI7'NO. + EH 13-24(REV.i/n5) Or EH 14-28 Or VVV