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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k 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 No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District. CityLot Size PM Job Address (� C Address Phone Owner's Name Address License Narie� I�� -Pho Contractor tWELL REPLACEMENT El DESTRUCTION LJ TYPE OF WELL/PUMP:: NEW WELL ❑ OTHER ❑ r PUMP INSTALLATION 171 SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D1SP05AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL O ELL PITS/SUMPS r, INTENDED USE TYPE OF WELL PROBLEM AREA CONST OSPECIFICATIONS ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing - ❑ Industrial - � Type© DomesticlPrivate ❑ Gravel Pack ❑ Trac T YP of Casin g Specifications Type of Graut 1-1 Public n Other elta Depth of Grout Seal — r i I Irrigation ---:.—.Approx th I I Eastern surface Seal Installed by Repair Work Done '❑ Type ump H.P. State Work Done Well Destruction ❑ ell Diameter Sealing Material (top 50') L Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION [\(Xb[\( septic system permitted if public sewer is ailable within 200 feet.) ! Other Installation will serve: Residence— Commercial Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: r SEPTIC TANK 171. Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. LJ Method of Disposal Distance to nearest: Well Foundation Property Line c LEACHING LINE ❑ No. & Length of lines- Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line 4 .< SEEPAGE PITS I'l Depth Size Number SUMPS ❑, '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 county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. rtify that in the performance of the work for which this permit is issued, l shall not Home owner or licensed agent's signature certifies the following: "I ce employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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 comp ensa- tion laws of California." The applicant m II for all re ed ins tions. Complete drawing on reverse side. gned X —Title: r Date. �+'FOR DEPARTMENT USE ONLY , Date r 3 Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by Additional Comments: L1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 M M1 CK BY DATE PERMI7'NO. _ FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVER C_... INfO ♦.EH 1324(REV.1/14 5) EH 14-26