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4 APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT ""'` a _J ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 v. D0 0 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) r-= ' :.i ', =, 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 k 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 I' Local Health District. Q' j 1(� k Job Address PSI SI u +/' °"R � 'a City 024; Lot Size PM I` Owner's Name ut1[ Address�Q d r Phone i Contractor Address � r�a'�-"�� License INo. 2 a ? Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ry SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1 i Other Cl Delta , Depth of Grout Seal Type of Grout _ I I Irrigation Approx. Dept l I Eastern Su ace Seal Installed by Repair Work Done � Type of Pump H-P., __State Work Done 4 f Well Destruction ❑ Well Diameter Sealing Material {top 50'I i Depth Filler Mafi riai /Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION-i-P DESTRUCTION f I (No septic system permitted if public sewer is r available within 200 feet./ Installation will serve: Residence_____ Commercial— Other C I Number of-living units: Number of bedrooms _ 4. Character of soil a depth of 3 feet: Water table depth, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k � PKG. TREATMENT PLT. ❑ Method of Disposal k Distance to nearest: Well Foundation Property Line E r LEACHING LINE ❑ No. & Length of lines Total length/size r I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS VI 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 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 applicanqipustcall for all required inspections. Complete drawing on reverse sidd. S Signed X � �-ffitle: )9 �t - Date: ry �i�% OR DEPARTMENT USE ONLY � �/ Application Accepted by ��Date Area Pit or Grout Inspection by _Date_ __ T' _Final.Inspection,. ]�'1 Data Additional Comments: ❑ Stk 466-6781 17 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 9''5201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY ry DATE ppP�ERM17'NO. + EH 13-24{REV-1/A51 ��'�� C•L Q— Z� �7-'Z3s� - EH 14-2e 11l s t