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{ APPLICATION FOR PERMITS SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA SEP 0 4 1070 Telephone (209) 466-6781 �• PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRQNMEN (AL HEALTH (Complete in Triplicate) PE 111/SERVIU_-S 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 welupump and the Rules and Regulations of the San Joaquin Local Health District. 5r 'J � � l Jab Address � � City �— ' Lot Size PM 12�/ o va �^�--' � -�'-' Owner Name Address Phone C _ ContractorlilP�� t Address p 4L f*n- 30� License No.V�53. .9952 Phan �- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMFNT ❑ DESTRUCTION ❑ PUMP INSTALLATION'iX, SYSTEM REPAIR OTHER. ❑ - ,,�, � �; ' —DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ADomestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications I`I Public f=1 Other ❑ Delta Depth of Grout Seal Type of Grout _ --A I I Irrigation _Approx. Depth I I Eastern�ealin Surface Seal Installed byRepair Work Done [Type of Pumpd �Well Destruction ❑ Well Diameter Material flop 50'1 . Depth Filler Material (Below 50'F _ Y TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is ' available within 200 feet.) ( n Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:. Water table depth SEPTIC TANK ❑ Type/Mfg r 6i -' capacity No. Compartments P KG. 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 I Depth Size -�_ _ Number '"" SUMPS"' 'L) Distance to nearestT -WeE4 Foundation Property Line DISPOSAL PONDS ❑ A 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 Di§trict. 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." �- i Signed X � Title: a�sido��R The applicant must c II for all required -nspections. Complete drawing on reverse Title:. -9L a� � , � .. Date: � � 1 DEPARTMENT USE ONLY 47 I Application Accepted by Date - 5 'ea Pit or Grout Inspection by ti Date Final Inspection by Date Additional Comments: i ❑ 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 CK it CASH RECEIVED BY DATE PERMIT'NO. a.EH 13.24IREV.1/x51 ..Mr"