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may. APPLICATION FOR PERMIT it SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 CDunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / It Job Address � -? Lam/ Lot Size PM l r -- City { Owner's Name - "`Address �� Phone J �� Contractor Address License No' Phone TYPE OF WELL/PUM NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing- Specifications l'l Public ❑ Other FI Delta Depth of Grout Seal Type of Grout fi^ 11 Irrigation Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H-P. State Work Done_ Wn Well Destruction ❑ Well Diameter Sealing Material atop 501 "t Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION l I DESTRUCTION l o septic system permitted if public sewer is A av ble within 200 feet.) Installation will serve: Residence—1 Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth p p SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments T PLT. Method of Disposal i PKG. TREATMEN L . ❑ J. Distance-to nearest: Well Foundation Property Line P Y LEACHING LINE ❑ No. & Length of lines Total length/size , i FILTER HED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth l! Size Number ,1 . SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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, 1 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." 'I The applicantmustcall for all requited inspections. Complete drawing on reverse side.nt / q Signed X- �i�.�� fi i Title: D Date: ` a FqAUEARTMENT USE ONLY n Application Accepted by Date V Area Pit or Grout Inspection by v Data Final Inspection by Date .4�z✓ Additional Comments: 9 5 5 ❑ Stk 466-6781 ❑ Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Enviro nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFEO AMOUNT DUET AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH 13-24 IREV.i/x 51 } 3 l" _ it } C `.2 £H t4-26 / �j f V rP