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j�,:.• x `" APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA , Telephone (209) 466-6781 N 0 PERMIT EXPIRES 11 YEAR FROM DATE ISSUED j ..., s" (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 decrib beds 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. Sa;f` r°,-• s ?, Joh Address ._ !��-[J �� City s��,^� Lot Size - PM Owner's Name r0AF&Address �vv rJ� Phone f Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑• PUMP INSTALLATION-Ll SYSTEM REPAIR ❑ BOTHER—❑ i DISTANCE TO, NEAREST: SEPTIC TANK SEWER LINES DIS P�ISA F7 LD. PROP. LINE a 'FOUNDATION'— AGRICULTURE WELL r^ OTHER WELL PITS/SUMPS r INTENDED USE 3 -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS $ ❑ Industrial I - ._j ❑ 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 ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by D, Repair Work Done Type of Pump H.P. State Work Done, "h Well Des on ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 4' ; Character of soil to a depth of 3 feet: . Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity— No. _ No. Compartments PKG. TREATMENT PLT. F-1t .;a' Method of Disposal Distance to nearest: Well Foundation Property Line x LEACHING LINE ❑� No. & Length of lines Total length/size FILTER BED ❑ ..Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑Depth Size Number +1 SUMPS ❑ Distance to nearest: ,Well Foundation Property Line DISPOSAL PONDS ❑ " 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state iawsr 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."Contractors hiring or sub-contracting signature certifies the following: ".1 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. l The applicant must call for all required inspectio s. Complete drawing on reverse side. a igned X y Title: , Date: FR DEPARTMENT USE ONLY Application Accepted by O - _ Y Ltirv�.� ) Date D Area Pit or Grout Inspection by Date Final Inspection b Date 0 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE, AMOUNT REMITTED CASH 'RECEIVED BY DATE PERMIT Np. + EH 13-241REV.ti85) T� �3�tJ, r EH 14-28 i