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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 t�,A► 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED dr�� (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 �/f/J rZ6 `- City Loi Size PM Owner's Name Address Phone Contractor's Name icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Lf DESTRUCTION ❑ k " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ + 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 ❑ 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 --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 q` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is tAavailable within 200 feet.) Installation viol/ serve: Residence— Commercial_L____�Other f Number'ofiliving units: Number of bedrooms _ 'CGacter.of'soil to a depth of 3 feet:• �' Water table depth SEPTIC TANK ❑ Type/Mfg ,. Z' Capacity�A'��Q Np. Compartments fF PKG. TREATMENT PLT. ❑ - `Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDDistance to nearest: Well!ISD Foundation Property Line __ SEEPAGE PITS ❑ 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 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 applicant must Al for all requi inspections. Com lete drawing on re c rse side. Signed Title, Act ✓f -e Date: S9 h 1 - 11.11.7 FOR DEPARTMENT USE ONLY Application Accepted by Date rea PR or Grout Inspection by Date Final Inspection by ' Date S & Additionalmments: El Stk 4661 ❑ Lodi 369 3621 ❑ Manteca 7104 ❑ Tracy 8354M5 Applicant- Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,-k, FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE,,'" PERMIT'NO. INFO �( CASH + EH 13-24(REV.10183) `,1� r��J 7� (� / v EH 14-26 L