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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��-�0 (Complete in Triplicate) ��{��v`R� ENTALvICs�� . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worgp r�1� . M'G' f1is application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules an�FTegulati s of the San Joaquin Local Health District. Job Address V City Lot Size PM Owner's Name /%$ !�"/ /¢�4.rf Pss Phone J r � ,,6i Phone Contractor Address � License No. s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ;1, 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 SOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r-1 Public f Cl Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation _.-Approx. Dept I I Eastern Surface Seal Installed by \\ Repair Work Done PK Type of Pump �T H.P. 46 State Work Done Well Destruction ❑ Well Diameter .. Sealing Material (top 501 Depth M Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION I 1 INo septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property-Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to clearest: Well Foundation Property Line SEEPAGE PITS l ) Depth Size Number t� SUMPS ❑ Distance to nearest: Well Foundation_ Property Line ' DISPOSAL PDNDS' ( ., .� ,.' _ ; , 7L 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 a '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 su m ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies The following: ' ce that in the rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californi The applicant must or a uired' Ions. Complete drawing on reverse side. Signed X y _ "' ""'Title:"""" Date: FOR D P'ARTMENT USE ONLY Application Accepted by f Date Area +> r Pit or Grout Inspection by L Date .t Final Inspection by DateR/ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT IVO. +.EH 13-24(REV. EH 11-28 C/✓ "'� ' ' 1