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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT IVB 1601 E. HAZE T ON AVE., STOCKTON, CATelephohe , 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'rp�G� 1~, � �,t P i�e fJn. ✓ (Complete in Triplicate) I'Np�RNFiI� 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. f} Job Address l/ 7Q f (2 City Lot Size PM Owner's Name c.� Address w- Phone Contractor AddressaV2 License No.--_.% Phone o� TYPE OF WFLL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE A IFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public �.`n Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation ..Approx. Depth I,I EasternS ace Seal Installed by Repair Work Done Type of Pumpnszt�• H.P. a State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 J -� Depth Filler Material (Below 50') ' tiz ' t TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIR/ADDITION 1 I DESTRUCTION I I (No septic sysiein-permitted if public sewer is available within 200 feet.] Installation will serve: Residence— Commercial— Other Number of living units: Number of-bedrooms s ,,;�•, Character of soil to a depth of 3 feet: `F Water table depth r rt` IZZ SEPTIC TANK ❑ Type/Mfg t-.r Capacity No. Compartments PKG. TREATMENT PLT. ❑ ! �,..,..,_, r ,. ..,. ri..a. . Method of Disposal Distance to nearest:: VWell Foundation ' n4 - -'Property-Line' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:" Well Foundation Property Line yr SEEPAGE PITS I 1 Depth r, Size _ Number SUMPS ❑ Distance to nearest:- Well Foundation Property Line DISPOSAL PONDS ❑ F' 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 became 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 appli call for all requi inspect: s. C plate drawing on reverse side. Signed X Title: �� Date: R;D4Pd1RTMENT USE ONLY ��Application Accepted by 1 Date Area_ _L, __ Pit or Grout Inspection by Date ' Final Inspection by 1� Date z� 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.O.:Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. a.EH13.24(REV.I K 5) :3 EH 14-29 I i' _