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G ►menti.«+�..y _w'f - .- �.' �. APPLICATION FOR PERMIT t SAN JOAQUIN`LOCAL HEALTH DISTRICT �jfJ1 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address �" rrfieDti �'GF City�1"OL'/� Lot Size �' � X l � •PM Owner's Name i�- E �iVEf, ddress � C�� f @ e- Phone ontractor oJ�L `Address �- � — License No. � Phone f. TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR E OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER DINES DIS SAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL THEA WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom 15 Manteca Dia. ell Excavation Dia. of Well Casing p� . h ❑ Domestic/Private � Gravel Pack ❑ Tracy ype of Casing Specifications 1 FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I kngapon --Approx. Depth I 1 Eas Surface Seal Installed by -Repair Work Done 17 -Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) " Installation will serve: -Residence� Commercial— Other r 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 PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number { SUMPS ❑ Distance to nearest: Well Foundation Property Line fDISPOSAL PONDS ❑ .. �, .__ , — ._ - ,.,,o. a -x • "-" -.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 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."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." The appliciint Inust call for all require spections. Complete drawing on reveVseidSigned Title: (J�[l Date: f FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspe y Date Final Inspection by -Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE pERMIT'NO. ` INFO AS �^ + EHr3-24lHEV.i/ns)