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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6.181 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. Yl Job Address City / ?� Lot Size PM r ' OwnName' a T ' — Address G J Phone 0 O I-V Contractor's Name f License No. Phone .--TYPE OF WELL/PUMP: NEWWELL 9WELL REPLACEMENT DESTRUCTION El PUMP INSTALLATION i SYSTEM REPAIR ❑ �O-T�'H�E,R ❑ R DISTANCE TO NEAREST: SEPTIC TANK w U SEWER LINES- 'DISPOSAL FLD.�� PROP..LINE ' FOUNDATION �� — AGRICULTURE WELL OTHER WELL_ pITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFlCATI N5 Dia. of Well Casing '1 ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation 9 Domestic/Private Gravel Pack ❑ Tracy Type of Casing ' K, Specications ❑ Public [] Other 4 E3Delta Depth of.Grout Seal Type of Grout ❑ Irrigation ---Approx. Deprh Eastern jSurface S al Installed by Repair Work Done El Type of Pump J H.P. State�Work Done t� E Well Destruction El Well Dlam ter t Sealing Material Itop 50')9 i te^,44 e - l Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is I ' I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 3 Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth I. i- capacity P SEPTIC TANK• � '❑ Type/Mfg � �•No. Compartments PKG. TREATMENT-PLT. ❑ Method of Disposal Distance to nearest: l Wel """ `Foundatidn Property Line F j I { LEACHING LINE ❑ No. & Length of lines Total length/size l FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS ❑ Depth t Size Number r SUMPS F-1 Distance to nearest: Well Foundation Property Line ,M 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 thatinthe 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."Contractors 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 Caliifornia.- ` Theapplicant ust call for all r quired inspe' ' Complete drawing on reverse side. �r ' t �� Date: Signed Title:: i # FOR DE_ARTMENT USE ONLY Application Accepted by y", , Date ,r� Area Pit or Grout Inspection by Date - "� Final inspection by g�F3-g P.r7i t 1f- r le r fb Verr r C a nDat�� Additional Comments: �' Cl Stk 466-6781 ❑ Lodi 369-3611 ❑ Manteca 823-7104 Tracy 83 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE DUE NFO AMOUNT REMITTED' ' H RECEIVED BY DATE PERMWINO. I 01 C1_ + EH 13-24(REV.WWI EH W28