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I 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 , k (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 (��/ rCy-a!/��lk'-� City Lot Size P Owner's Name Address `' Phone "4Contfactor Address License No. Phone TYPE OF WELL/PUMP,. „'NEVI)WELL'❑. WELL REPLACEMENT ❑ h DESTRUCTION j{ PUMP INSTALLATION ❑ ,SYSTEM'REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; - ' DISPOSAL.FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial r © Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private." �© Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public •❑ Other FI Delta Depth of-Grout Seal Type of Grout I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pum H.P. J P Yp P -State Work'Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 x a. Depth _ Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATIOfiEPAIR/ADDITION IV DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence= Commercial_ ther 1 Number of living units: —I— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capa'ciiy �_'No. Compartments PKG. TREATMENT PLT. ❑ 4. Method of Disposal Distance to nearest: Well Foundation Property.Line , LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Zell Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line p 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 k 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 app7Title: nt t for u'reqspections.Comp) a drawing o verse side. Signed _�-yj��xgz Date: iT7 FOR DEPARTMENT USE ONLY ^]� Application Accepted by Date _ e_9 Area v Pit or Grout Inspection by Date Final Inspection b Date L Additional Comments: _ µ I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT-NO. INFO CASH +.EHf3-24 4REV.1 i H sl ��V E EH 14-28 �/�/ lT