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APPLICATION FOR PERMIT $/a ' SAN JOAQUIN LOCACHEALTH DISTRICTvs 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �t I (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 es rM; f4"�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. ;,i?i -„ Job Address City Lot Size PM Owner's Name Address �� 5Cs? y. J Phone —� a I Contractor's Name icense No./ 46- o./�� 3 Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ SWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ~ SYSTEM REPAIR 2--' OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELLi PITS/SUMPS INTENDED USE TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing li&mestic/Private ❑ Gravel Pack '❑Tracy Type of Casing Specifications ❑ Public 1:1Other :� Delta Depth of Grout Seal Type of Grout ❑ Irrigation JAppr= Depth r❑ Eastern Surface Seal Installed by 1 - Repair Work Done fi' Type of Pump H.P. State Work bone, Well Destruction ❑ Well Diameter ' Sealing Material Itop 501 ` I Depth Filler Material (Below 501 "4 TYPE OF SEPTIC WORK: NEW INSTALLATION..0 REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is f available within 200 feet.) Installation,wilf_serve_ Residence'>_11- Commercial__ Other Number of living units: t Number of bedrooms `• W M - T Character of soil to a depth of 3 feet:! I 'Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity" � No. Compartments j PKG. TREATMENT PLT. ❑ "+ Method of Disposal Distance to nearest: Well Foundation . Property Line V LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ]j Well Foundation Property Line 111\\\ SEEPAGE PITS ❑ Depth Size iE !`Number i l SUMPS ❑ Distance to nearest: Well Foundation.' Property Line DISPOSAL-PONDS '.. ❑ 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. e i 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."Contractors 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 t ca for all rjRquired in t ns.in Complete drawing on reverse side.,r ` Signed X b !�"L�Title:�� Date: l FOR DEPARTMENT USE ONLY Application Accepted by 06 Date ` Area �1 Pit or Grout Inspection by Date Final Inspection by ofAZ41 Dated Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 �- ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 -Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE pPERMWT NO. +EH 1324(REV.10193) � y -2,41—9-T 11 EH 14-26 „3 i i