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APPLICATION--FOR .PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZE-LTON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR"FROM DATE ISSUED ` (Complete il.Tripllcate} °' Application is hereby made to the San Joaquin Local Health District.for a permit to construct arid/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1952 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. E . , 'w .r'•ti , Job Address / �.31 � � ,f "` City' " '"` "+`Lot Size �t r' PM C..��✓f .n _ r.1 _ ., 1'�sf =Owner's Nam/e� res~ Phone t ContractorAddress �a 1 License Noi _.�? _Phone�� I TYPE OF WELL/PUMP: NEW WELL" ❑'- WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION O SYSTEM REPAIR .Ci OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA—CONSTRUCTION•SRECIEICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .. ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout "1 ❑ Irrigation —Approx.,Dept ❑ Eastern Surface Seal Installed by Repair Work-Done—Wl"Type of-pump H.P: Z JrY. State Work".Done –d� f Well Destruction . ❑ Well Diameter Sealing Material (top 50') F r Depth Filler Material {Below 501 - F -TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,y available within 200 feet.l Installation will serve::`,. Residence Commercial_ Other F s Number of living units: Number of bedrooms Character of soil to a depth of 3-feet: Water table depth ` f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ?^ T ;Method of Disposal € Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ Na. & 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 DISPOSAL PONDS ❑ is`t j Thereby 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 applicant st c I for all re ired inspe +'ons. Complete drawing�chnfpverse side. i Signed X _"—Title: Date: FOR PEPARTIMENT USE ONLY F Application Accepted by Date f" `` Area ' Q t l Pit or Grout Inspection by Date Final Inspection by Date f Additional Comments: " r i ❑ Stk 466-6781 ❑ Lodi 369-3521 It Manteca 823-7104 ❑,Tracy 835-6385 f Applicant- Return all copies to: Environmental He'aith Permit/Services 1601 E. Haz'elton Ave., P.O. Box 2009, Stk., CA 95201FEE r INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE: .PERMIT"NO. - + +EH 14-24(REV.t/ss) ' .: EH 1426 �`