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j APPLICATION FOR PERMITS' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NOI,J Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED NO (Complete in.Triplicate) �4s1 �-� IR3,—, 4A 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. « - Cit r } Job Address � `" " y Lot Size PM r Owner's Name dress f � Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH I❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing k ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications i'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal.Install ad by _ Repair Work Done H.P. State Work Done_ F Well Destruction ❑ Well Diameter Sealing Material (top 50'1 - Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i I-REPAIR/ADDITION.I I DESTRUCTION "INo septic system permitted if public sewer is Is , vailable within 200 feet.) I -.- Installation will servel Residence__,__ J-4 Commercial Other Number of living units: Number of bedrooms . "t a� r Character of soil to a depth of 3 feet:" Water table depth ^�► SEPTIC TANK ❑ Type/Mfg Capacity No. CompartAents u PKG. TREATMENT PLT. ❑ Method of Dilposal Distance ttyo.nearest: Well ,o�undation,»�__ Property Line �� 1� LEACHING LINE ❑ No. Lengtfiroi Tines "" To al length/size , FILTER BED ❑ Distance to nearest: " Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS Cl 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 followin certify-that in-the-performance-of..the-work,forwhich this permi[is issued,"1 shallemploy persons object to workman's compensa- tion laws of California"' The applicant must call for all re wired 'ns C110 . Complete draw"rng onfreevv'Serrsre'side.,) f f Signed X *4 � Tit e':: "" ! - Date: OR DEPARTMENT USE ONLY ` Application Accepted by ��A— Data `� Area Pit or Grout Inspection by Date iFinal Inspection byGi(�.0 -- Date Additional Comments: - Q-�Vw� -3 [o{° ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH ]��J ..EH 13-24 MEV.11051 �� V EH t4-28 t