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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ILIA V1RaSM,A� A/ �$ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install' the work hV,$9 �.cTibed. 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 ; V 1 1 �-Qi'Vj _ City Lot Size PM Owner's Name r Address ip�J * .:/ Cp•a6-� � Z Phone —_ e'_1 _ t Contract -Address TYPE OF WELL/PUMP: NEW WELL ❑ PUMP INSTALLATION ` DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION . INTENDED USE Q Industrial Domestic/ Private M Public I i Irrigation Repair Work Done ❑ Well Destruction ❑ License No.s WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS -2-- Phone J W TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L1Gravel Pack ❑ Tracy Type of Casing Specifications n Other f-] Delta Depth of Grout Seal Type of Grout _Approx. Deptlk I i Easternf r Surface Seal Installed by Type of Pump ..ft`�— H.P. _f�,_ State Work Done Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 I YPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I ) Installation will serve: Residence — Commercial _ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Capacity Distance to nearest: Welf Foundation LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: ION I I (No septic system permitted if public sewer is available within 200 feet.) Water table depth No. Compartments Method of Disposal . Property Line Total length/size— Well Foundation Property Line SEEPAGE PITS ( I Depth Size SUMPS 0 Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Number Property Line 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 r 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 mu Il for all required inspections. Complete drawing on reverse side. Signed - Title: Date: FOR DE RTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT' NO. + EH 13-241R".1/xsl� 35.I_ChQAo/ � I Eli 1429 \.rT �"� 1