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,', �• }, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 Telephone [209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED l (Complete in Triplicate) lo � � '�� 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. �^�� a j f� _ �£.�' City Etot Size �/�� PM Job Address _ f Owner's Name JC1f fc�'• � Address Phone/ -1 AJ Contractor �L_v Address n License No. z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 F] Industrial ❑ Open Bottom > ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ., . ❑ Domestic/Private ❑ Gravel Pack , ❑ Tracy Type of Casing Specifications F i`l Public f Other Cl Delta ` Depth of Grout Seal- ° " Type of Grout — I I irrigation ;^_.-Apprax.°Depth I Eastern E, Surface Seal Installed by-_- - — - Repair Work Done El #Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'i, Depth +-_ F" Filler Material-IBelow 50'1 TYPE OF SEPTIC WORK:..NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted it public sewer is 0 available within 200 feet.) Installation will serve: Residence Commercial Other ! Number of living units: J— Number of bedrooms .12 Character of soil to a depth of 3 feet: Water,table depth s ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `� 4 PKG. TREATMENT PLT. ❑ c Method of Disposal Distance to nearest: Well t Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' i Total length/size FILTER BED ❑ Distance 40' nearest:-.. Well Foundation Property Line SEEPAGE PITS ['I Depth Size �.L x Number F• " SUMPS X Distance to nearest: Weil � Foundation-`11 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 Di%tricti. 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, 1 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,t shall employ persons subject to workman's compensa- tion g Y tion laws of California.".. ` The applicant m st call for all required ins action Complete drawing on reverse side. Signed X '_� - Title: r Date: FOR DEPARTMENT,USE ONLY ,., ,t / Area Application Accepted by Date f /l/" Date 6 I Pit or Grout Inspection by Date Final inspection by I Additional Comments- 0.Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE MOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. INFO r"EH 13-24 iREV.t/K 51 f / IJ EH 14-26