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APPLICATION FOR PERMIT f 'SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. H�ZELT,ON`;a'VE„ STOCKTON, CA — = Telephone (209) 466-6781 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 Joaqum County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` PM Job Address SAddress _ `-'� �� 1� Phone + w Owner's Name i Contractor dress License No one TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION El 'f SYSTEM REPAIR t*. OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPQ�AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ &HER�WELL- PITS/SUMPS ` INTENDED USE TYPE OF WELL PRO13LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca, ' , ;Did of Well Ex�vation Dia. of Well Casing ""`' Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i pe Depth of Grout Seal = Type of Grout ❑ Public El Other ❑ Delta ❑ Irrigation �4pp-ox: Depth ❑ stern Su a� Seal Installed by s _ Repair Work Done Type of Pump H.P. State Work Done Z Sealing Material {top 50') i x Well Destruction ❑ Well Diameter 9 i �� illi Depth 'I Filler Material IBelow 56 1l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ {No se tic system permitted if public sewer is available-within 200 feet.) Installation will serve: Residence:_ Commercial_ Other 1 ' Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size y� 4 FILTER BED El Distance to neareStr'; �;Weil �NrA�-t ` t�,rFoundation Property Line , SEEPAGE PITS ❑ Depth Size Number SUMPS Pro Line ❑ Distanice to nearest: Well Foundation Property DISPOSAL PONDS* ❑ ! I hereby certify that repered this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regula ns of the an Joaquin Local Health District. Home owner licensed ag is signature certifies the,following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ an rson in suc a ner as to a ome sub t workman's compensation laws of California."Contractors hiring or sub-contracting signature r certifies t e following:" ce that lin t rm ce ft work for which this permit is issued,I shall employ persons subject to workman's compensa tionla of a." J The plicant ust all re ns. a late drawing o e side (T Sign d Title: Date: 6 � _ # R DEPARTMENT USE ONLY Date 5; Area Application Accepted 97 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all F copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT UE AMOUNT REMITTED CK f9ECEIYED BY DATE PERMIT'NO. FEE 'CASH INFO �1 + EH1&24(REV.i/a5) EH 14-2' -