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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES .i YEAR FROM',DATE ISSUED �5,i0 ren 2� (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 a Local Health District. 4 Wl 2- Job Address t r 1 City Lot Sizef PM Owner's Name Address `Y 2-6 —�— -� Phone216 Contractor's Name � ef4,•�nse No./ r f Phone(! —, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LJSYSTEM«REPAIRAff/I OTHER 11 ` DISTANCE TO NEAREST: SEPTIC TANK y SEWER,LINES '-.- .:.DISPOSAL FLD. PROP, LINE FOUNDATION .AGRICULTURE WELL 4 OTHER`WELL PITS/SUMPS INTENDED USE TYPE,OF WELL PROBLEM AREA s CONSTRUCTION SPECIFICATIONS 1} O Industrial ❑ Open Bottom ❑ Manteca ' Dia of Well Excavation Dia. of Well Casing 'Ja ❑ Domestic/Private El Gravel Pack [3 Tracy 'Type of Casing `� Specifications ❑ Public ❑ Other ❑ Delta Depth of,'Grout Seal ' I'frri ation El of Grout 9 _Approx. D Depth Eastern Surface Seal Installed by f Repair Work Done .Type of Pump 1 j I,p, G State Work Done Well Destruction Q tWei l Diameter. S aling Material (top(top . " Depth I Filler Material (Below 501) ' TYPE OF'SEPTIC`1NORK-NE1111"INSTALi ANON-❑—REPAlR7ADDITUWD' DESTRUCTION ❑ (No septic system permitted if public sewe r.' available within 200 feet.) ,p 4 .I Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil-to-al depth of 3 feet:' I Water table depth Q"' SEPTIC TANK ❑ Type/Mfgi Capacity No. Compartments PKG. 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 I Property Line + � SEEPAGE PITS ❑ Depth 11X Size Number SUMPS ❑ 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 SSan 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 i certifies the following:"I certify that in the performance of the work for which,this permit is issued, I shall em Io tion laws of California." } Yf p Y Persons subject to workman's compensa- f The applicant t cal for all re u �t. q pections. Complete drawing n reverse side. Signed X I tle: Date: r FOR DEPARTMENT USE ONLY Application Accepted by all IDate �� r Area Ph or Grout Inspection by Date Final Inspection by 3 Additional Comments: ( Y-1�i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7.104'" ❑ Tracy 835-6385 .0 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box-2009, Stk., CA 95201 E FEE AMOUNT DUE AMOUNT REMITTEDCK INFO ASH RECEIVED BY DATE PERMIT"NO. + EH 14-24(REV.10163) S , f%1--1,L4.--1� f FH 1426