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APPLICATION FOR PERMIT ` 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) rpa cation 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 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 l Health District. I AddressX e- r �- City Lot Size PM er's Name �r�lfAN* 3, r!`01Ze/c Address �� aX Z f ` Phone f, r I Contractor 2 �1 Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DI POSAL FLD. PROP. LINE f FOUNDATION A RICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private El Gravel Pack ❑ TracySpecifications e of.Gasing = l i ❑ Public Li Other ❑ Delta Dep of Grout Seal I Type of Grout p I I Irrigation —..Approx. Depth i I astern Surface Seal Installed by ' _ Repair Work Dane ❑ Type of Pump H.P. 'State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50') N Depth Filler Material (Below 50' i' TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIWADDITION l I JTESTRUCTIOIUWN6 septic system permitted if public sewer is y vailable within 200 feet.) Installation will serve: Residence, Commercial_ Other i Number of livi6g units: Number of bedrooms (\ Character of soil-.to a depth of 3,1l l l Water table depth �J SEPTIC TANK '. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 # Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length-of lines Total length/size I FILTER BED D Distance to nearest: Well Foundation Property Line `r SEEPAGE PITS ['I Depth i f _� a' Size _ Number i SUMPS ❑ Distance to nearest: Wel! foundation Property Line ' DISPOSAL PONDS ❑ """"""'" I hereby certify that I have prepared this application and that the work will be done.n accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.) I I— Home owner or licensed agent's signature certifies the following; "I certify that in t�id I f�armance 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,1 shall employ parsons subject to workman's compensa- tion laws of California." I ' The applicant must call for all required inspections. Cbmplete drawing on reverse side. i I �. IN Az Signed ' Title: �' Date: FOR DEPARTMENT USE ONLY > It Application Accepted by l Date` G ) a / Area ` Lam, Pit or Grout lnspe ' n by Date _ _Inspecti n by - Dat d �� a , 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 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. + EH1144-26-24(REV. EH i/851 110-2Z-67�7-3 �� '