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c R APPLICATION FOR PERMIT. I' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 !� PERMIT EXPIRES TYEAR 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. Job Address City Td�1 � City- ✓, Lot Size /00)( J PM Owner's Name �7r �_ Address� � .+ � Phone f r r 7�" �N Phon'15A940 / Cbntraor � f Addres License N � � cf , TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O- I DESTRUCTION`❑'` ` - j RUMP-1 N STALLATION,El— .-___-..,,,,,.,SYSTEM,REP,AIR 0. , t�.�'OTHER 0 I DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD -;PROP. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout e rj YP - I I Irrigation --Approx. Depth l 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 --v Filler Material (Below,50') 1j TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/-ADDITION I I DESTRUCTION (No septic system permitted if public sewer is 1 K available within 200 feet.) I 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 Capacity No. Compartments l PKG. TREATMENT PLT. ❑ Method of Disposal - i Distance to nearest: Well Foundation Property,Line l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well `Foundation c Property-Line SEEPAGE PITS I I Depth I Size __..-Number _-- t SUMPS 'Ll 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 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 must for `all equir in cti Complete drawing on ars side. Signed X �� Title: Date: lr`d !I 4 # OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Dat F' al Inspection by Date Additional Comments: 1 e z� ❑ Stk 466-6781 ❑ Lodi-369-3621 ❑M 104, O 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 CASH RECEIVED BY DATE PERMIT'NO. ♦.EH 13-24(REV.1/H 51 � �3 tka 1EH 14-28