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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZETON AVE., STOCKTON, CA �1 G] oGo — � 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. t / Y Job Address �fJ–h; City Lot Size PM Owner's Name r P1 Address Phone )ell Contractor Address License W. Ma. Phone 9 k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r�• FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS ' INTENDED USE TYPE.OFFWELL 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 F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done �. .: Well Destruction'!j'r ❑ -� Well Diameter � Sealing Material-(top 5i5'I`"T""-`�'�"`" Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I -PAIR/ADDITION I I DESTRUCTION I I (No'septic system permitted if public sewer is }*" available within 200 feet.i Installation will serve: Res dente Com ercial /ter Ther` � s ' Number of loving units: I Number of bedrooms _ I Character of soil to a depth of 3 feet: C Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ s Method of Disposal Distance to nearest:- —Well , Foundation Property Line LEACHING LINE tNo: & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: WhIl" ------w---Foundation—'Property Line SEEPAGE PITS 41pth Size_ Number N SUMPS Cl Distance to heare3t: r Well Foundation Property Cine r 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. 51 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- Zapplica alifornia." , m c II for Ire red itc�rawing on verse sid Title: _ Date: ? +�74 ZIFO =ENT USE ONLY Application Accepted byDate LAPit or Grout Inspection by Date Final Inspection by el L"C[.; �ate � rt�y rL� t Additional Comments: � C�• �i L �•+-- �- ��,� - ❑ Stk 466-6791 ❑ Lodi 369-3621 V ❑ 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 FEEa INFO UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +,EH t -2e(REV.1/H 5) � EH 14-28 (. O t�.l L '