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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE.,.,STOCKTON, CA L 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. 1962 for welUpump and the Rules and Regulations of the San Joaquin I Local Health District. Job Address `"' et. City�- Lot Size PM 171 Owner'Owner's Name Ph Address i one l Contractor �C ddress r License No. 1 �Phone a TYPE OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMEIVT ❑ DESTRUCTIO r PUMP INSTALLATION D "f SYSTEM EPAIR*❑ OTHER !Q0zk 61 DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES 100 DISPOSAL FLO. PROP. LINE _Zt FOUNDATIONf 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 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`l Public ❑ Other ❑ Delta Depth of Grout Seal- — - -Type of Grout I I irrigation —_Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �d Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence____ Commercial_ Other - Number of living units: Number of bedrooms T ! 'Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT" PLT. ❑ o.�, } Method of Disposal Distance'to nearest) -Well Foundation Property Line LEACHING LINE; ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance 16'nearest: ,Well Foundation Property LineA r SEEPAGE PITS I I Depth Size: Number "- :t SUMPS `L� 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 app licantcall f r all a irreed i ctions. Complete drawing on side. �m C Signed Title- _ ` - Date: qi VJ FOR DEPARTMENT USE ONLY Application Accepted by Date Area / Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-3621 O !Manteca_823-7104. _-0-Tracy- 835-_6M5._ Applicant--�RetuZ all copies to- Environmegtal Health_P�r�it/S es 11 Hazel o�A`ve.4.0. Box1L109, St , CA 95201 � W CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 7 I +.EFl t3-24(REV.r i k 5) EN 14-2a r _