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]2 L of r.2 a cr✓ APPLICATION FOR PERMIT SAN JOAQUIN LOG L' FCEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR 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. i Job Address v� / � �� il.t.Q' ~___ _ City Lot Size Ig7 PM Owner's Name . dressy/__ ./ _�-1//_r___ Phone Contractor ddressnse No� - Phone 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 4 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public ❑ Other ❑ Delta Depth of Grout Seal_ Type of Grout 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 ealing Material (top 50') t�. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION I I DESTRUCTION 1 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: _L_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments TP PKG. TREATMENT PLT. ❑ w Method of Distws Distance to nearest: Well ®� Foundation _._._ Property Line v LEACHING LINE A�No. & Length of lines Tlength/size C FILTER BEd EJDistance to nearest: Well Foundation ._. . Property Line ^ AZ SEEPAGE PITS I 1 depth Size Number i PS Ll Distance to nearest:" Well Foundation Property line i 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 subcontracting 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 call for all requ' inspections. Complete drawing on erse side. p Signal X Title: ��1L�Y�� Date: s , I 114 FOR DEPARTMENT USE ONLY Application Accepted by C Date 1 p Area Y, Pit or Grout Inspection by Date Final Inspection by b - [/�.0 Date 5 r/ Additional Comments: ❑ 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 95291 FEE INFO AMOUNT DUE AMOUNT R TE ASH RECEIVED BY DATE r PERMI7'NO. + EH13-24(REV.r/H5) EH 1428 S