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r -sem• � 1 APPLICATION FOR PERMIT SAN JOAOUIN,LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone {209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED , ®. AComplete in Triplicate) sale. f` w 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health"District: Jab Address "� nC ty c/r Lot Size PM Owner's Name Q��d`� Address` ` z, c Phone Contractor Address "�� t License Ho. Phone 6 Q TYPE OF WELL/PUMP: ITEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \� i 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE I 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 p Domestic/Private Q::Gravel Pack ❑ Tracy Type of Casing Specifications j'❑ Publics ❑ Other ElDelta Depth of Grout Seal Type of Grout r ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Donee ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ;REPAIR/NDDITION ❑ DESTRUCTION VINo septic system permitted if public sewer is available within 200 feet.) Installation wily serve: Residence Commercial " Other Number of living units: 'Number of,bedrooms ' Ch atter of soil to a depth of 3;feet: E Water table depth 'SEPTIC TANK f ❑ Type/Mfg _ Capacity _ + No. Compartments PKG. TREATMENT PLT. ❑ µ - Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE h ❑"No. & Length of.lines Total length/size l FILTER BED ❑ Distance to nearest: Well _'foundation 'Property Line SEEPAGE PITS ❑ Depth s Size Number ' SUMPS ❑ .Distance to.nearest: Well Foundation � Property tine 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. j Home owner or licensed agent's signature certifies the following: "I certify that in the performance Jof 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-faws-6f-California." Contractor's hiring or sub-contracting signature certifies the followin ' '9 certify tintn the performance of the work fort which this permit is issued, I shall employ persons subject to workman's compensa- Ation;laws of Cali rnia.' � Thej-applicant ust I for a required inspections. ' Com,plet-e drawing on—reverse side. kTitle: Date:Siged X 4 , . 5R FO�DERARTMENT USE ONLY Application Accepted by A,A "lltin [av+n�✓� Date Z� ^� O"Area Pit or Grout Inspection by Date :-' Final Inspection by Date F Additional Comments: 1" ❑ Stk 466-6761 ❑ Lodi 369-3621 Q Manteca 6237104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y 1 FEE s MOUNT DUE AMOUNT-REMITTED CK RECEIVED,BY DATE PERMIT'NO. INFO CASH ?7+ EH 13-241REV.1/y 5) S fOD —3o_P7 • —'i? EH 14-26 -