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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. ¢� Cepp j/.q Job Address _ !✓ - City Lot Size/ d�/1 tsL� PM Owner's Nam Address 1^1194�r,1 1 !/t/dd a 'a.5k 3 �i e ContractorAddress � f License NofV f5�Phon 42-71 TYPE OF WELT/PUMP: NEW WELL R WELL REPLACEMENT ❑ if DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Z �Q4 ZVI DISTANCE TO NEAREST: SEPTIC TANK .. SEWER LINES DISPOSAL FLD _'*O PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Indust tai- ❑ Ope ottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing h 9�, omestic/Private Gravel ack ❑ Tracy Type of Casing Specifications M Public er f Delta Depth of Grout Seal Type of Grout�. i I Irrigalion —.-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 Vj TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i-1 1DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) s Installation will serve: Residence_ Commercial_ Other. Number 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 d j PKG. TREATMENT PLT. ❑ Method of Disposal b Distance to nearest: Well Foundation Property Line ,. LEACHING LINE ❑ No. & Length of linesTotal length/size ?s FILTER BED 1:1Distance to nearest: Well 4 Foundation Property Line SEEPAGE PITS i I Depth Size Number a. SUMPS CI 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 f ich er s ice§issued, I shall employ persons subject to workman' compensa- lion laws of California." P t��5 The applicant must call for all required/inscoms. Complete drawing on reverse side. c i . Signed X Title: a Date: 7 r i FOR DEPARTMENT USE ONLY- Application Accepted by '� G Date 1 L � Area C) r f s i Pit or Grout Inspection b/y, ' Dater Final inspection by Date ; Additional Comments: 1� 7 ❑ Stk 466-6781 ❑ Lodi 369-3621 " ❑ Man& ca 823-7104 ❑ Tracy 5-63854,/q Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CSC 95201 r/ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO y +'EH 3-24 ME FiN51 (y�fJy 'r/'a ^ EH 14-2e '-'^ G T G'''7d ��