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' r ' APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rt'~ 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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. y7 Job Address –5 ©/ I SPL City Lot Size PM Owner's Name Address . Phone Contractor . Address C) License No Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ElOpen Bottom LI Manteca Dia. of Well Excavation Dia. of Well Casing $-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Q I I Irrigation Depth 4 I Eastern Surface Seal Installed by Repair Work Done `- Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.! 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 T SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Rl PKG. TREATMENT PLT. ❑ Method of Disposal TN Distance to nearest: Well Foundation Property Line (0 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS [ I Depth Size Number SUMPS CI 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 taws 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 applicant mus II or all repuiWA inspections. Complete drawing on r versa side. '7 Signed X Title: ��— Date: F DEP RTMENT USE ONLY Application Accepted by Date ' Area G Pit or Grout Inspecslon by Date In Final spection by Date q/22�6f C,lct wed! fa �e i s —.co f ��dcr cr C-1 f £L ,eco F4 rs- Qa Y at wcU -;rwZa Additional Comma is. ❑ Stk 466-6781 ❑ Lodi 369-3621 EAAanteca 823-71 ❑ Tracy 835-&3t5 C«e r out— 4 - Applicant- Return allcopiesto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ^ '�•�'f" f1ZLl�y– Pyl rr ok - -Vo a'UZ .4—bc - FEE !AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*No. INFO CASH [} fry Q + EH 13-24iREV.r/R5) 35 ! �+r V EH 14-26