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�.f4, ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address ( ,?, o un! CitySCQ On Lot Size PM Owner's NameQ Vrddress0 � Phone Contractor 1 1 &S4 d`, ` dress � License o27 Phone 5_T sio� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION � S PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ { `a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 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 q Tracy Type of Casing _ Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Pone Well Destruction ')Weil Diameter Sealing Material (top 50 � Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 13—REPAIR ❑-"•DESTRUCTION`-❑x(No-septic`system`perniitted if'public sewer,is- available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms t 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line a DISPOSAL PONDS ❑ ^' 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. `b"L 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 suti-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 io workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. 4 11 eTitle: Ij `�Signed XW - � r s t 7q.lufu FOR DEPARTMENT USE ONLY r ' Application Accepted by Date —27 Area O" Pit or Grout Inspection by Date Final Inspection by Date 7— i Additional Comments: r ❑ Stk 466-67$1 ❑ 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 CK# RECEIVED BY DATE PERMIT'NO. INFO / CASH + EH 13-241REV,1/e 51 3S J �" gH �f-17'- EH 14-28