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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �1 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f 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. l Job Address r Cit Lot Size PM rr t S=_3061 Owner's Na Address / Phone Q F Cont rac r ( ' Address�.�. �l2 Gr License No. � � Phone��a'SrQ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE=M 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 Cl Industrial s ❑ Open Bottoms ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F] Domestic/Private y� ❑ Gravel Pack 'i ❑ Tracy Type of Casing Specifications ,„ E7_P_ublic _ Other 'T.,n Delta, j .Depth of Grout Seal. Type of Grout. I I Irrigation —"Approx. Depth I I Eastern, Surface Seal installed by _ f� Repair Work.Done ❑ Type of Pump State Work Hone Well Destruction -❑ Well Diameter Sealing,Material (top 50') ?, Depth Filler- atmal (Below 50'E s • �_ ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION-T) -DESTRUCTION-"I ]-INo'septic system permitted if,public sewer is J j available within 200 feet.] Installation will'_serve: Residence_ Commercial Other r" - `► r ,r r Number of diving units:--!. Number edroo s 0 Character of sail to a depth of 3 fee(: Water table depth r� SEPTIC TANS( Type/Mfg r sy Capacity d No. Compartments PKG. TREATMENT PL Cl `C _ Y `�� Method of Disgosal I Distance to nearest: Well ��. rF_oundation . � Property Line LEACHING LINE` No. & Length of lines f Ttotal.length/size FILTER.BED f. ❑ Distance to nearest: Well. Foundation AQ :Property Line SEEPAGE PITS Depth Size "s r - Numbe SUMPS Cl Distance to nearest: Well_1:1� Foundation Property Line S 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. t 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." f The applican all for I re it inspections. Complete drawing on reverse id " Signed X Title: - �- + Date: FOR DEPARTMENT USE ONLY Application Accepted by"'—.4Dates i /-/� Area O '7 Pi r Grout Inspection b Date� /t - Final inspec ion by , Date ^ Additional Comments: / � � r";? v v�� r ,+ ❑ 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 2 S�k�CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH r r�� ' + EH 13-24 EH 14-26 { (REV,r i n 51 t Vt� 1 L 1 V