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FOR PERMIT - 5 APPLICATION , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 y 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. + 2 City L�'�=J----��Ijy� � Lot Size PM Job Address ___ 1j / �J�° Address �, s'? � ' ""� Phone �� Owner's Name � - �l Address L'e - dz.• r �tLicense No. Phone Contractor ___. TYPE OF WELL/PUMP: NEW WELL ElWELOREPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION❑ SYSTEM REPAIR ❑ ' DISTANCE TO NEAREST::.SEPTIC TANK SEWER LINES AL FLO. PROP. LINE } FOUNDATION AGRICU Y ELL OTHER WELL PITS/SUMPS t� iNTENDED USE TYPE OF WELL PR M AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ] ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private ❑ Grav ack © Tracy i Type of Grout l"1 Public ther n Delta Depth of Grout Seal _ I I Irrigation __Approx: Depth t I Eastern Surface Seal Installed by Repair Work D ❑ Type of Pump IA.P. 1 State Work Doe Well De ction ❑0.Well Diameter Sealing Material Itop 50'1 Depth Filler Material IBelow 50'I s TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION_ TN0 Se availabpeiw within feet.) if public sewer is l Other will serve: �Residence_ .Commercial� 0 - �r s . 1rf z Number of Jibing units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth \ SEPTIC TANK ❑ Type/Mfg 4 Capacity No .Compartments Method of Disposal PKG. TREATMENT PLT. ❑ 14 :I ` Distance to nearest: Well Foundation Property,Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 1 Foundation Property $Line SEEPAGE PITS I I Depth Size 1 Number SUMPS D 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 J aquin county ordinances, state laws, and `kt 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 cosub contracting signature mpensation taws of California." Contractor's hiring or certifies the followin 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." ti The applicant mus call for all required c' ns. C plate drawing on raver s I At Signe Title: Date FOR DEPARTMENT USE ONLY Date Application Accepted by Area Pit or Grout inspection by Date Final Inspection by Date r 0 Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 J ❑ 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 s AMOUNT AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO a CASH -ell t +.EH 13-24[DEV.i/N sY s �s- -� - EH 14-25