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' APPLICATION FOR PERMIT G �'' SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. �j Job Address � ! City r, at Size PM Owner's Namel C Address" ? Chid (/ fD AV phone Contractor,,—/, .4 • Address 00-B 4!a� nse No, hone 57A2 TYPE OF WELL/PUMP: NEW WELL CF 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 171 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation "Apprpx, Depth t"I Eastern Surface Seal Installed by Repair Work Done IU Type of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material (top 50') Depth Filer Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPA€R/ADDITION I 1 DESTRUCTION l (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other vailable within 200 feet.) 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 Pro t4 pe rty.Line i LEACHING LINE ❑ No. & Length of lines ' Total.length/size C FILTER BED r. ❑ Distance to nearest: Well Foundation tr Property Line SEEPAGE PITS` ! r'r If'1 De " .} Pth Size Number SUMPS D Distance to nearest: Well Foundation l Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquih county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for allrequiredinspections. Complete drawing on reverse side. ./ Signed X ' _ Title: FOR DEPARTMENT USE ONLY Application Accepted by Date Are Pit or Grout Inspectio y Date Final Inspection by Date Additional Comments: 0� �- < e�"�"` ❑ Stk 466-6781 ❑ Lodi " •3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �•r! ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009! Stk., CA 95201 -el FEE AMOUN# DUE AMOUNT REMiT YED ��_��_ f INFO CK H RECEIVED BY DATE PERMIT'NO. 4 . +.EH 1 -24(REV.1/8 sS (� EH 1 4-26 �.J � I