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;.i,,, = ;".'j,:.,, APPLICATION FOR PERMIT l" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. Job Address A�f f 7.- -� � City T Lot Size PM Owner's Name, Address f ��/J� s,�- Phone Contractor 4,tZ Address f License No. Phone TYPE OF WELL/PUMP: NEW WELL.❑ - _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 Ll ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications — [7 Public Ll Other Cl Delta Depth of Grout Seal Type of Grout . i Irrigation Approx. Depth l 1 1wstern�. Surface Spal Installed.byY_ Repair Work Done ❑ • Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 �. Depth. Filler^Material IBelow 50'1 TYPE OF.SEPTIC WORK: NEW INSTALLATION € 1 REPAIR-/ADDITION ! I DESTRUCTION. (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg +- Capacity No. 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 Property Line SEEPAGE PITS I 1 Depth' Size_- Number t SUMPS L-i Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ x 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."Contractors Hiring or sub-contracting signature i certifies the following:"I certify that in the performance of the work for which this permit is issued;Isallemploy persons subject to workman's corrpensa- tion laws of California." r The applicant must tali for re d inspections. Complete drawing on reverse side. ' Signed X d Title: C / Date: l OR DEPARTMENT USE ONLY f Application Accepted by .tL..ym,�^ Date `" Area Pit or Grout Inspection by Date Final Inspection by Date jr t Additional Comments: r d, ❑ 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 A$H RECEIVED BY DATE PERMIT'NO. t EH 13.241REV.1in5) � f EH 14-26 -