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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 (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. 1� y Job Address O L, `� City ' Lot Size f� X `� f PM if_ fi 1 ' n17Q Owner's Name. S �1 t} i�G _Address.,, P m n �' _P_hone- T `'f '! I Contractor's Name n '-le Li ense No. - Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C] i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FL'D. - 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 Typekof Casing Specifications Q t ❑ Public EDOther ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --L4pprox.•Depth ❑ Eastern- - -Surface;Seal-'Installed by- I Repair Work Donee EJType of Pumps H.P. State Work Done E. Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth ''w Filler Material (Below 50') _ } TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 8 available Within-200 feet.) Installation will serve: Residence Commercial_ Other } Number of living units: _ Number of bedrooms" Character of sail to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Ce-MP1r n- Capacity CZ " �Zaa No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well � Foundation 0 Property Line .._ ,. i , LEACHING LINE No. &Length of lines / Total length/size /•T FILTER BED ❑ Distance to nearest: Well Al On 'P_ Foundation_ 161 Property Line Z� -P L SEEPAGE PITS ❑ Depth S Size ' a � �4 Numbed k SUMPS ❑ Distance to nearest: Well_.v Oe-Eoundation_ Property Line C� i DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature certifies the following: "I ce 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 rrlu for all require ctio . C wing on reverse side. Signed - R Title: Date: D A SE ONLY pplication Accepted b Date-- a 3 Pit or Grout Ins . io y to d ,Final Inspection b Datep 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 . DATE PERMIT`NO. ' INFO -- — CASH.- EH 1324(REV.10M) -+� S Y � q�� ry Q:A- �Y LV g V i`t.9 L i EH 14-28