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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA _ 11 r Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED �P (Complete in Triplicate) HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harem ENVId ribe `s�p��c made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and RR i�sIif�t .Sfa" n Local Health District. / G6 Job Address City Lot Size PM Owner's Name Address Jr (o Phone J -1 Contractor Address License Nq!_�� 7� �Phony 6 � f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing CJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Oiher n'Delta Depth of Grout Seal Type of Grout _ I�Irrigation �T` rnx'*Depttt :l I Eastern Surface Seal Installed by 5 , M Ory Repair Work Done L�- Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material atop 501 .� Depth p '-� Filler Material (Below 50'I F TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sev%i&-is - ' �` � available within 200 feet.) Installation will serve: Residence Commercial_ Other r Number of living units: Number of bedrooms 4 , - �,. __ Character o} soil to a dept o eat: Water table depth SEPTIC TANK ❑ Type/Mfg. 4�_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' : z Method.of Dis _sal c } p " Distance to nearest:"-`i Welly-- -- ----Foundation - ' — -" 1 Propertq Cirre {LEACHING LINE ❑ No. & Length of linesf r Total length/size FILTER BED ❑ Distance to nearest: 'Well Foundation :Property Line SEEPAGE PITS I I Depth Size Number SUMPS Distance to nearest: Well Foundation Property. Line 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 R rules and regulations of the San Joaquin Local Health District. t 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." P The applica t ust call,for allr uir d ins q pections. Complete drawing on reverse side. t Signed X 41 � / Date: f / / FOR DEPARTMENT USE ONLY 6 Application Accepted by I/Z�1,'iw.`o1� -- Date Area Pit or Grout Inspection by Date Final Inspection by r D'atg Additional Comments: . I-) Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-638-5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AF AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO. INFO /�� CASH ..EH 13-24{REV.i i H 51 (�/�v ��•^ �I�� '