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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTINCT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209Y 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NIAL HI_AL.TF4 (Complete in Triplicate) EN111p,OVlw VVMITAERVICES Application is heiaby 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 Dis/idiot..–�, Job Address � City Lot Size PM Owner's Name AddressQ 0 r�ry(iC� t+ ` phone t r, �'�-use. -e�. Ca• 5 a Contracto Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALIATION,( 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 SPECIFICATfONS El Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing %Domestic/Private © Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public I-1 Other Cl Delta Depth of Grout Sea! Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Werk Done 04 Type of Pump H.P._- Bk.e� State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [7 REPAIR/ADDITION I I DESTRUCTION t I INo septic system permitted if public sewer is �}1 Q Installation will serve: Residence— Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms 0 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.p Method of Disposal Distance to nearest: Well Foundation Projierty Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ! SUMPS 0 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 counI rules and regulations of the San Joaquin Local Health Dllstrict, ty ordinances,state laws, and Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this employ any person in such manner as to become 6ubiect to workman's compensationpermit is issued,I shall not certifies the following:"I certify that in the performance of the work for whicthlaws of California,"Contractors hiring or sub contracting signature tion laws of California." permit is issued,I shall employ persons subject to workman's compensa- The applicant must It atl requiradrns clions. Complete drawing on re ame side. Signed Title: Date: Fp DEPARTME�IUSL�01JLV Application Accepted by Date d I Area Pit or Grout Inspection by Date Final In spection by Aare Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑Tracy 835-SM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, Hazahon Ave., P.O. Box 2009, Silk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASHRECEIVED BY DATE PE1tMlt'NO. ..EH 13-2+IREY.a/i451 EH ts•2e � O g� G