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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. r Job Address ity Lot Size PM Owner's Name s Phone Contractosslf,9441p�� - e IVo.q/Phone Z " TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLAjION Q/ SYST M REPAIR LV OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES Atli DISPOSAL FLD r PROP. LINEi FOUNDATION AGRICULTURE AELL OTHER WELL ITS/SUMPS IN DED USE TYPf OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA 0 S r Of/ ndustrial pen Bottom ❑ Manteca Dia. of Well Excav n 5 0 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'] Public i.71 Other F1Delta Depth of Grout Seal Type of Grou I I Irrigation --Approx. De th I I Eastern Surface Seal Installed by _ Repair Work Done L] Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter _ Sealing Material Itop 501 Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I 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 SEI}TIC TANK ❑ Type/Mf�. v Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ �. 3 Method of Disposal Distance tv�rlea` rest; Well Foundation Property Line LEACHING LINE ❑ .No. & Length of lines Total length/size FILTER BED `❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS "e. ' L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 persons subject to workman's compensa tion laws of California." The applicant mu I or all r quit specti S. Complete drawing on r so side. Signed X Title: Data: —� R DEPARTMENT USE ONLY Application Accepted by Date al (� Area Pit or Out Inspection by ate Final Inspection by j2ff f-4 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO -91 'AMOUNT DUE AMOUN"TREMITTED� CA - RECEIVED-BY ] DAT/-E— PEFiMiT'N0_ + EH 1 11-29 3-26(REV..1/K51 EH 116�6 1 P /// V IVC/ r