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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ll't0 _e) i 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 /11Ae40 1 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. r � Job Address / t/� City Lot Size PM I t 9uOwner's Name 1 Addressr ` Phone —t/y Contractor. 4Address. /... r✓ aZAU License No i-0 .Phone 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 FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS RU ION SPECIFICATIONS ❑ Industrial El Open Bottom L) Manteca -- Dia. o ell.Excavation__ .._., ._._ pia. of Well Casing {=1 Domestic/Private ❑ Gravel Pack ❑ Tracy r Typ Casing Specifications {l Public F Other Cl Delta pth of Grout Seal Type of Grout 1 1 Irrigation ___Approx. Depth ( I Eastern Surla a Seal Installed by _ Repair Work Done ❑ Type of Pump H.PZ State Work Done_ Well Destruction ❑ Well Diameter SeaMaterial (top 501 Depth Filler Material (Below 50') r -- TYPE OF SEPTIC WORK: NEW INSTALLATION I]- REPAIR/ADDITION I 1 kUCTIONI!ep tic stem permitted it public sewer is o /� ble w' hin 200 feet.) Installation will serve: Residence— Commercial'=' Other IBJ ju_el Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 1 Foundation Property Line f LEACHING LINE ❑ No. & Length of lines f Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation_ Property_Line s SEEPAGE PITS ( I Depth Size _ Number SUMPS [_1 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,irr'accordance with San Joaquin county ordinances,!state laws, and rules and regulations of the San Joaquin Local Health Di§trict. r 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- tion laws of California." The appiican ust call for required in ctions. Complete drawing on reverse side. Signed X Title: _ Date: ' k 4 �y FOR DEPARTMENT USE^ONLY q VIVU F Application Accepted by Date Area I Pit or Grout Inspection by Date Final Inspection by � Date I Additional Comments: ❑ Silk-466-6781_._,...,,.0-Lodi-.-369-3621-----❑•Manteca.-823-7104--13 Tracy-835=&385--- Applicant.- 35=6385^^^Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOU E ITTED CK 9 RECEIVED BY DATE PERMIT NO. INFO ` CASH +.Eli 13-24(REV. 5) EH 14-2B