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APPLICATION FOR PERMIT �` 1 l,Q SAN JOAQUIN LOCAL HEALTH DISTRICT /� Y 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 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. �-3 -2 2- S /�`1{ /V _ City ��V Lilot Size � ' PM Job Address Owner's Name f Address ��" / Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El j PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _—_—_Y DISPOSAL FLD. PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS LINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `{LJ► Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private E� Gravel Pack G Tracy Type of Casing Specifications f-1 Public n Other 71 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by i - Repair Work Done ❑ Type of..Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') pth Filler Material (Below 501 TYPE OF SEPTIC WORK: �EW INSTALLATION I I REPAIR/ DITION I I DES RUCTION I I INo septic system permitted if public seweri is av iia a within 200 feet.) Installation will serve: Residence Commercial_ Other - ` �� Number of giving units: ."—Number of b6dT(Zms• Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity ZAV No. Compartments PKG. TREATMENT PLT. ❑ JnMethod of Disposal Distance to nearest: Well Q Foundation Property Line ` 1 LEACHING LINE ff No. & Length of lines _ Tot�l length/size FILTER BED ❑ Distance to nearest: Well oundatibn Property Line — 4EEPAAGPIT`S I 1 Depth Size Number ❑ Distance to nearest: Well Foundation Property Line IDIS ❑ I:hereby certify that I have prepared this application and that the work will be donee in accordance with San Joaquin county ordinances, state laws, and miles and regulations of'the San Joaquin Local Health Di§trict. Home owner or licensed agent's s)gnature certifies the following: "I certify that in�the performance of the work for vv"this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation law(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 shalt employ persons subject to workman's compensa tion laws of California.""-- - - ' The applic t u call for all r quired in ctio Complete drawing on reverse side. Signed X /�..C'Yf'/� Title: FO MENT USE ONLY Application Accepted by Dataj6Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: El Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 D 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 CASH RECEIVED BY DATE PERMIT NO. INFO f.EH 13-24 1REV.ri n 5) // 5— EH EH 14-26 ll//