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,a �. APPLICATION FOR PERMIT SAN'JOAQUIN LOCAL HEALTH DISTRICT •, 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t Q f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address • — ��`` City Lot Size PM Owner's Name &We&e:o. Address �� Phon�T/`��✓ 7o r'W-cSt��'/ Contractor- Address �yW 9� License � Pho TYPE OF WELL/PUMP: NEW WELL.❑ - WELL REPLACEMENT C1 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST" SEPTIC TANK SEWER LINES DISPOSAL FL INE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED�USE TYPE 6F WELL- PROBLEM A O1g9TRUCTION SPECI IC�ITIONS: i ❑ Industria[V ❑ OpentBottom ❑ eco Dia. of Well Excavation l Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑"Tracy Type of Casing i Specifications f'! Public / 17 Other f.-1 Delta Depth of Grout Seal Type of Grout 1 I i Irrigation *� .Approx. Depth I l Eastern Surface Seal Installed by { Repair Work Done Type of Pump H.P. State Work Done i Well Destruc " ❑ Well Diameter Sealing Material (top 501 t Depth 's j Filler Material (Below 50.1 S '� TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION l I DESTRUCTIO lNo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— C-ommercial Other Number of living units: Numbe,loll beldrooms Character of soil to a depth off3 feet: t f Water table depth SEPTIC TANK Type/Mfg Capacity 40DNo. Compartments ' PKG. TREATMENT PLT. ❑ < Method of Disposal ; Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation I Property Line ,_1 r' 1 P SEEPAGE PITS { I Depth � Size f Number y 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 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." f The applicant=sll for all required ins ctions. Complete drawing on reverse side. i I Signed X 'Title:. / Date: F� �.5 FOR DEPARTMENT-USE ONLY Application Accepted by �^�'! `� Date Area �d _ Pit or Grout Inspection by l Date Final Inspection by Date Additional Comments: - 7 3 - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' I FEE INFO AMO�UNNT DUE AMOUNT REMITTED /CASH RECEIVED BY DATE PERMIT'NO. k + EH 13-24{REV,t i HS) EH 1429