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APPLICATION FOR PERMIT f 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) 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`. y7 ,• ' 1 Job Address 7 �LJ �P/ 11f �L CitygoA.,LhLot Size PM Owner's Name t✓!' -� ��6��G'� Address 41`7d 4✓401 Phone Z 7 Contractor `�� + Address Peg q71 License No.(AW&6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ _WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION T SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I f'l Public n Other ❑ 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') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONK REPAIRIADDITION (.I DESTRUCTION i I (No septic system permitted if public sewer is ' f available within 200 feet.) i Installation will server Residence Commercial_ Other Number of living units: Number of bedroo s fCharacter of soil to a depth of 3 feet I Water table depth SEPTIC TANK ❑ Type/Mfg - , Capacity aA67 Qf No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well 40 Foundation Property Line 1 LEACHING LINE No. & Length of lines .Z Total length/size gey FILTER BED Distance to nearest: Well ../-Sb Foundation Property Line 1 fz SEEPAGE PITS i I Depth I Size S _ 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. 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 suchi-rai6ftner as to:become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifie<h, certify t the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion la The ap fpr al wired i pections. Complete drawing on reverse side. �y Signed Title: MDEPARTMENT +rnnUSE ONLY C ;� Application Accepted by C��r Date Area t t Pit or Grout Inspection by Date Final Inspection by Date r ;6 e 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 FEE1 INFO OUNT DUE AMOUNT REMITTED ASH{{'�CK RECEIVED BY DATE PERMI�T�jN�O. ...,EH 13-24(REV.t i K sY �q"� /d' I" EH 14-28 R t V tJ !D c