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APPLICATION FOR PERMIT Its-- r4- SAN JOAQUIN LOCAL HEALTH DISTRICT lfe55 r l(,e 5_er_&>^J 1601 E. HAZELTON AVE., STOCKTON, CA 6 v,nc hr I,- Kc — 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 'I Local Health district. Cr CCc rlydll nt Ibb Address City Lot Size PM" .hone..... _ ; owner's Nart .,..�-,4.._.-t....�......,-.....-s--r\ ----"^-�----- - _-_. _rte..-.m..._--,-,...P. ..S L..�5-}"--�-'q�'•^....F-.--.-,..,rW'-..+�!".N,.�.�.,.....»,-------'�'"� _• - Contractor Address k License No. Phone. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 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 3 ;' ❑ Industrial ❑ Open Bottom ❑ Manteca. ,�'i _Ula. of Well Excavation Ria. of Well Casing y ❑ Domestic/Private ❑ Gravel Pack ❑_Tracy---`' Type of Casing Specifications y " ' ❑ Public ❑ Other yam. r `❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') n Depth Filler Material (Below 501 TYPE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) ' Installation will serve-,,*Residence'" Commercial Other y , Number of living units: ! Number of bedrooms MCharacter of soil to a depth.of 3 feet: Water table depth_ SEPTIC TANK ❑' Type/Mfg ; Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 'V Distance to nearest: Well Foundation Property Line f • i Total len LEACHING LINE ❑.."No. &_Length of Iines" th/sizes 9 FILTER BED--- "ry❑ "Distance,to nearest: Foundation Property Line p SEEPAGE PITS ❑ Depth f. Size ' ?" Number SUMPS ❑ ,Distance to nearest: We11 ` t Foundation i Property Line i F DISPOSAL PONDS ❑ + 1 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." Contractors 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 s tion laws of t o ia." The i app t must call f II uired spections. Complete drawing on reverse side. `, ! # 1 x Signed X Title: 4 Date: r FOR DEPARTMENT USE ONLY " Application"Accepted by Date Area 6 Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 (D 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 ry FEE AMOUNT-DUE "" AMOUNT REMITTEDSH' RECEIVED BY DATE PERMIT'NO. INFO + �] � "� ♦ EH 13-24 IREV.t/A 51 C](, rye ...O G�� r �.�.. 3��3�� 1 i0 1 EH 14-28 - - �.. --•.— -