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q t 4 I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 � 1601 E. HAZEL T ON AVE., STOCKTON, CA ,, i Telephone (209) 466-6781 PERMIT EXPIRES 11YEAR FROM DATE I$$UED" (Complete in Triplicate) `;. k" 4 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 R41es and Regulations of the San Joaquin Local Health District. h s Job Address City+ Lot Size PM ' Owner's Name IZI. �11�1 e�C'V. Address= Z Phone Contractor Address 6 icense No. Phone W 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 1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 9 Manteca Dia. of Well Excavation Dia. of Well Casing 2'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other o ❑ Delta ,, Depth of Grout Seal. Type of Grout ❑ Irrigation -----Approx. Depth ❑ Eastern'- Surface Seal Installed-by Jis Repair Work Done � Type of Pump H:P. ra a Work DoneWeII Destruction ❑ Well Diameter *-= Sealing Material (top 50'1 Depth Filler Material (Below 50'1TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if pu available within 200 feet, Installation will serve: Residence 4 Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i r Water table depth SEPTIC TANK ❑ T e/Mf ca Type/Mfg g p aci ty No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance�to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance'to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth .'w Size Number SUMPS ❑ Distance nearest: Well` �' Foundation Property Line DISPOSAL PONDS ❑ t §f _ 4 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 F 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- tion laws of California." The applicant must call for all required inspections. Complete drawing on re side IViS gned X Title: Date: !r �FORTMENT USE ONLY ,0 Application Accepted by PV z `" Date Area 4 Pit or Grout Inspection by ��- Date FinalI sn pection by date 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 95201 FEE AMOUNT DUE_ AMOUNT REMITTED RECEIVED BY DATE. PERMIT`NO. INFO + EH 1428(REV.s/e 5) ex�