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5 t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 �_�` �– ��t? City Size _<2t06G(2I PM 71 Owner's Name A ss ��2 Qmnok.ne ContractoAddress License No. Phone TYPE OF WELLIPUMP: NEW WELL-❑ A WELL REPLACEMENT ❑ -DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca x Dia. of Well Excavation Dia. of Well Casing El Domestic/Private C Gravel Pack ❑ Tracy ,q Type of Casing Specifications M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ "g 1 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by a _ Repair Work Done ❑ Type of Pump -H.P--' State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ' Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I. DESTRUCTION (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence \X/, Commerlial_ er Number of riving 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. ❑ t Method of Disposal Distance to nearest: Well Foundation I Property Line 1 s LEACHING LINE ❑ No. & Length of fines 1 Total length/size j FILTER BED ❑ Distance to nearest: It Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS F1 Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ 1 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 applica st call for all reqSkired inspect. S. Complete drawing on r se sid ! /4::;� Signed Title: Date- FOR DEPARTMENT USE ONLY Application Accepted by Date ,+�J Z Area Pit or Grout Inspectio .�Daater / Final Inspection by_rte JDate /, Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 PEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. INFO }CASH + EH 13-24 MEV-1/"51 35^ 00 j�? �•�a,t�,r DCA cP�'-) £H 14-26 - v O