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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601, E. HAZELTON AVE., STOCKTON, CA Telephone 12091_466-6781 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r. (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 : G City TLot Size PM „ry ' Owner's Name � � � Address � P f' -?,9�7 Phone Contractor + Address_� �� rPf �`� 3'��_lcense nZE �3y Phone �76i6 TYPE OF WELL/PUMP: NEW WELL CJ WELL REPLACEMENT ❑ DESTRUC_TION ❑ .PUMP INSTALLATION E3 SYSTEM REPAIR ❑ O`fHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ,'SEWER LINES DISPOSAL FLD.- PROP. LINE,- LL �� FO AGRICULTURE WEOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open.Bottom. ❑ Manteca Dia. o xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,Type of Casing,i "L Specifications ❑ Public Ll Other ❑ Delta f Depth.of Grout Seal Type of Grout yx ❑ Irrigation �pprox.;Depth Eastern _ Surface Seal Installed by Repair Work Done ❑ Type of Pump ter-- H.P. ' State Work Done X / Well Destruction ❑ Well Diameter "' Sealing Material {top-50')•. _r= rf Depth, Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑p REPAIR/ADDITIONI.DESTRUCTION ❑ (No septic system permitted if,public sewer is— available within 200 feet.) Installation will serve: Residence_ Commercial— Other t "1 - E ! Number of living units:' Number of b1 edrooms Character of soil to.a depth of 3 feet:. °--- -- - - ater table depth SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments 1. PKG. TREATMENT PLT. ED ! ! Method of Disposal Distance to nearest: Well Foundation Property Line L I LEACHING LINE ' No & Length of lines }i /�T _ Total length/size �� `• l FILTER'BED ❑ Distance to nearest: Well Foundation Property Line /r SEEPAGE PITS i 1] Depth Size Number SUMPS ❑ Distance,to nearest: Well Foundation___-� Property Line DISPOSAL PONDS. ❑ 1 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 ma er as to become subject to workma4l, compensation laws of California."Contracto�s'hiring or subcontracting signature certifies the following:"I c hat 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 c f uired ' clip mplete drawing on reverse side. F f " Signed Title: _ Date: 7 Z FOR DEPARTMENT USE ONLY �} Applicaiion"Accepte&by mm 1 "T Date "' Area 2f Pit or Grout Inspection by � Date Final Inspection by Date C' ditional Comments: iWtk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy•"835 386,1 Applicant- Return all copies for Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95101 FEE INFO AMOUNT DUE- AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. -.. EH 1428 + EH 13.24(REV.1/s 51 O - - ... .. .-.