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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 Jo quin aunty rdi ance No.549 for sewage or No. 18P2 for well/pump and the Rules and egulations f the S n Joaquin Local Health District. �� � 4 �✓��/� .p��ya / tj,�� .�a D�f 4 �'/zf Job City Lot Size PM Owner's Name Fes , / _ _ _— Phone ' t Contractor ddress License Nor' Phone3 I TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1. INTENDED USE TYPE OF WELL 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 _ M Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation �..Approx. Depthr-t-I-Eastern— -Surface-Seal-Installed4*0u _.. _ .._ _ > Repair Work Done ❑ Type of Purn'p H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 t - - Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION i IR /ADDITION l i . DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.)' Installation will serve: Residence--"_"- "Commercial Other f k Number of living units: Number of bedr oms 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D, „r .. -. 1Method f Is osal s / t � y z . Distance to nearest: Well Foundation Pro�Pert Line r r LEACHING LINE ❑ No. & Length of lines T9tal length/size FILTER BED ❑ Distance to nearest: Well �6 Foundation .__.__.._._. Property Line 6_7 r EEPAGE PITS I 1 Depth Size x ! Number. s D€' Distance to nearest: `” Well�� ._-- Foundation Property Line DISPOSAL PONDS ❑i; i 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, 1 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 nrimptPor I quire -in tions. Comp at drawing on re side. Signed X-6— I' Title: _ Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date 7/7 Area 1 it PitorGrout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. *-EH 13-24 1 REV.i int 7 y EH 14-2e