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f 5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON`AVE., STOCKTON, CA v41 + Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED , 9 (Complete in Triplicate) \,r'el `�Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hdes abed. This applicaii6n'Es I; made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of thb-`San dapquin Local Health District. I Job Address 49 Irl r City S of Size PM Owner's Name G-- Address 0. ✓�� s Phone Es Contractor tG—c_�LC.CL[7 Lint [- Address d` �� rY! c� r�_Q License No.R770Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I� ("I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ ii I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done IS/ Type of Pump H.P. _ State Work Done = Well Destruction ❑ Weil Diameter Sealing Material Itop 501 i Depth Filler Material (Below 50')1 t 11 TYPE OF SEPTIC WORK; NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I i lNo septic system parmitted'if public sewer is I, available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line -71 II 0r I r i LEACHING LINE ❑ No. & Length of dines Total length/size FILTER BED ❑ Distance to nearest: } Well Foundation Property Line C „ SEEPAGE PITS g l I Depth Size Number ` E 'SUMPS `" s 0 Distance to nearest-'j 'We'll 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 Di1trict. Homeowner 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 i 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- n tion laws of California.', € The a pl' m st call for..all requir spectio . Com a drawing on reverse side. Signed X Title:-._ �P� Date: �i E y FOR DEPARTMENT USE ONLY ; �`� j Application Accepted by Date Area I E: Pit or Grout Inspection by Date Final Inspection by 1a Date n ! Additional Comments: l Ei ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE E' INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. -EH 13-24(REV,F/n5) 3Sc�t� CA GF + 4?1 4y f3J� I: EH 14-2e V