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APPLICATION FOR PERMIT ( '� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED T (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."" n Gf Job Address �� cy i City ��r Lot Size PM S ,' u Owner's e _ Address Phone ' .4 Contra Address.1 License N -S3 U_ Phone�_JW TYPE OF WELL/PUMP: NEW WELL ❑ �,r^"' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 1NSTALLATION.�r: SYSTEM REPAIR ❑ OTHER ❑ C ,� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF W7 ELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approxi Dep ❑ Eastern Surface nstalled by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter-_—'^ = ' Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other A__/ Number of living units: Number of bedrooms "'Ai ? Character of soil to a depth of 3 feet:k Water table depth SEPTIC TANK ❑ :--Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. ❑ " t L,-' Method of Disposal —Distance to nearest: —Well -- --- Foundation Property Line LEACHING LINE ❑ No. & Len th of lines 9 Total length/size 1 FILTER BED vj ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS t ❑ Depth Size Number 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 Joaquirs 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 Ycertifies the following: "I certify that in the performan of the ork for which thispermitis issued, I shall employ persons subject to workman's compensa- tion laws of Calif r,ia." f! d r The applica u call for all required inspec oComp a drawing o arse side. Signed / Title: i 1, Date./- - 4 FOR DEPARTMENT USE ONLY Application Accepted by 2_94__""" Date l ' 7 �� Area Pit or Grout Inspection by t \ pate - Final In on by D Additional Comments: ❑ Stk 466-6781 Lodi 36916IM11 ❑ h .ca 823-7104 " ❑ Tracy, 835-6385 F11r�, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE "if/s INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE,,/ IyPERMIT`ND. ✓ + EH14-25-24IREV.t/esl15H 17�fr_.Yln n fl tyVV� I r