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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Fit 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 [N� PERMIT EXPIRES TYEAR FROM DATE ISSUED B. I_ (Complete in Triplicate) _ , l San Joaquin Local Health District for a permit to construct and/or install the Rork herein des Regulations he San Application is hereby made to the S q Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for well/pump and the i/4 Local Health District. r r City Q�`r�! Lbt Size PM Job Address Phone Owner's Name ss 11 1:32 4 17 Contractor ' `� Address Lice se No Phone c r TYPE OF WELL/P P. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION in- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Ll Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic I Private --G1-Gravel-Pack ©Tracy• - YP g Type of Grout W r'l Public S 71 Other _ Ci Delta Depth of Grout Seal \ 1 1 Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITIONI 1 DESTRUCTION (Nailabptic )hisystem relined if public sewer is Installation will serve: Residence, Commercial Other r - Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity J — � No. Compartments PKG. TREATMENT PLT. ❑ _ _ � - � �- l Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l l Depth Size Number SUMPS Ll 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 District.-- 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,k shall employ persons subject to workman's compensa- tion laws of California." The applica t rail require i s lions. Complete drawing on rev rse side. � . Signed Title: Date: � TMENI' USE ONLY j Date Area Application Accepted by . Date Pit I Pit or Grout Inspection by --77 Date Final inspection by Additional Comments: °�O�`3�U l�. ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK _ RECEIVED BY DATE PERMIT'NO. 1NF0 .CASH (J Q 1 + EH 13-24(REV.t/n 5) `� / ��' ✓��`� � / �� /151 ' EH 14-26 J � v