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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 /� 'S:40 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. r7�• 'fin .(,��.j_� r r t. _ ',3-) t„y„ -�”' .. _ Job Address T '`� City Lot Size PM f Owner's Name v V R N Address �'� fYjiI Z Phone . 1�1 Contractor 1. .. Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A 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 C1 Manteca 1 ''61a. of Well Excavation pia. of Well Casing 111 ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy". Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 17Irrigation --Approx. Depth : ❑ Eastern Surface Seal Installed'by nV t� Repair Work Done ❑ Type of Pump ?y. H.P. State Work Done '^ Well Destruction ❑ Well diameter Sealing Material (top 50') R, Depth . , p Fille"r Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑v DESTRUCTION (No septic system permitted if public sewer is 4 til available within 200 feet.) Installation will serve: Residence Commercial, Other fir; t' Number of living units: Number of bedrooms Character•of soil to..a_ depth of 3'feet: Water table depth SEPTIC TANK ❑ Type/Mfg•, # Capacity___:y t No. Compartments PKG. TREATMENT PLT. ❑ y J Method of Disposal Distance to nearest: Well !£ foundation f Property Line. LEACHING LINE ❑ No. & Length of lines '* Total Length/size FILTER BED ❑ - Distance to nearest:. Well Foundation Property Line}' t ' t i SEEPAGE PITS ❑` Depth Size Number SUMPS LIDistance,to nearest: Well i foundation °Property Line t 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. Home owner or licensed agent's signature certifies the following�l certify that in the performance of the work for which this permit is issued, I shall not r_ employ any person in such manner as to become subject to workrtian's compensation laws of California." Contractoes 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 r uire .ins Ion Com drawing on reverse side. Signed X �� Title: -_ Date: ILr U�dr 4 4Y FOR DEPARTMENT USE ONLY Application Accepted by Date Area F;i Pit or Grout Inspection by Date fr' ! Final Inspection by Date[ Additional Comments: r r ❑ Stk 466-6781 _ Lodi 369-2&1._ ❑_Manteca:823-7,104,-i,—C]-,Tracy..,..835-6385- +Applicant-- Returnl,,a opii to: Environmental Health Permit/Services 1601 E: Haze_Iton Ave , .P.O. Box 2009, Stk., CA 95201 y •` '^✓� 1.1W- �. FEE AMOUNT DUE AMOUNT REMITTEb INFO �} ASR RECEIVED BY DATE PERMIT NO. + EH 13-24 fREV.'i EH 14-28 l� 3A-s5 �+'� l✓ l