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APPLICATI6N FQR*PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE.T ON AVE., STOCKTON,`CA (� C Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE !$SUED '�a �� ; � •- ^ (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein.des'ribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/purtlp and the Rules and Regulations of the San Joaquin Local Health District. + Job Address Q J 1 City t srze PM ,.x Owner's Name e.J ! I/1 1hl_ Address t7 � f .,ate Y�co.�.' �Phone Contractor's NameLicense No. Phon€: ^7 vC TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION -SYSTEM REPAIR _ R ❑ «� I DISTANCE TO NEAREST: SEPTIC TANK. ' '.SEWER LINES. �• ^DISPOSA� fLD PROP IrI.�E, = – FOUNDATION.' AGRICULTURE WELL OTHER WELL PITSI$lJlNPS:"T 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 Speclfioations ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ,Y Type.of Grout` ❑ Irrigation g ---Approx. Depth Eastern —Surface Seal Installed'by Repair Work Done )A Type of Pump ❑ H.P.' r w State Work Done e L. - Well Destruction ❑ Well Diameter, "'Sealing Material (top 50'1 4 -a 11 Depth j Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ©'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ..- '_ available within ZD feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms ► Character of soil to a depth of 3 feet: p Water table depth SEPTIC TANK ❑ Type/mfg r Capacity No. Compartments , PKG. TREATMENT ALT. ❑ Method of D'isposal, „ r Distance to nearest: Well Foundation Property Line AS 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 4-1 '- 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: "I certify that in the performance of the work for.which this,pe,miit 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 applic calf for all re =plete drawing on roside. ` aJ Signed Title: 702 S _ Da#s FOR DEPARTMENT USE ONLY Application Accepted b DateA 7 L r yQ,MW1 Ph or Grout Inspection y Date Final Inspection by 9> Date _^� 7 . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009^Sok.;CA 91a20� r - INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATS PI2gMiT"NO. r ; + EH 13-24(REV.10/831 l EH 14-2$. S' - -.