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- - i APPLICA.,.OW FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .� (Complete in Triplicate) ; Application is heieby 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. f ` i Job Address City Lot Size. PM Owner's Name .. Address Phone 's Contractor Addres Cv L(CJ S LicenseA Phone Rko? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑.- DESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ;' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELLPROBLEIVIAAE_A` CON STRIJGTION,SPECIFICATIONS i i ❑ Industrial ❑ Open-Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1R Domestic/Private ElGravel Pack 1-1Tracy Type of Casing k Specifications �^ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 9 --Approx. Depth ❑ Eastern Surface Seal Installed by L' 3: Repair Work Done Type of Pump :5—V�- H.P. __ Stafe'Work Done tf Well Destruction L7 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION D- (No septic system permitted if public sewer is ' t 1 :available within 200 feet.) _ Installation will serve: Residence— Commercial,— Other— Number J1fJl 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 PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well —Foundation tProperty Line g LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 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 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 permrit 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 rnia." The icant Test call for all ired ins coons. C I plate drawing on averse side. Signed ` " "- S ry 4 F Title: Date: 9"a� "d 2 ` FOR DEPARTMENT USE ONLY Application Accepted by r Date 10 Opt* Area v�— Pit or Grout Inspection by Date Final Inspection'by Date �L 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 95201 m. _ - FEE INFO AMOUNT DUE AMOUNT REMITTED'` ' CKI#LCASH/ 'RECEIVED-13.Y DATE PERMIT NO. + EH 13-244REV.7/851 EH 14-28 '