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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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 F Local Health District. VJob Address I / City Lot Size PM t Owner's Nam Address ga Phone A�- Contracge" Addressb A"7 License No, hon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -+ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ° r FOUNDATION 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 i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 I'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approx. Depth l 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') Depth Material (Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLA_TION (1 REPAIR ADDITION �DESTRUCTION I I (No septic system permitted if public sewer is `_// available within 200 feet.) h Installation will serve: Res'dence_ Commercial_ they d� Number of living units: 77 Number of roo Character-of soil to-a depth of 3-feet:- Water table depth SEPTIC TANK ❑ Type/Mfg — Capacity No. Compartments PKG.•TREATMENT PLT. ❑ �� _; r! Method of Disposal 7� Distance to nearest: Well Foundation Property Line F--. LEACHING LINEjrNo. & Length of line's: Total lengthlsize FILTER BED ❑ D si tance to nearest: Well Foundation _ Property Line SEEPAGE PITS Depth rS zr e, Number C ~-! SUMPS L] Distance etto nearest: Well"11M_.__ Foundation �D Property Line _ G DISPOSAL PONDS ❑ A� - I 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,is_sued,.l sh_a_II_employ persons subject to workman's compensa- tion laws of California." The applicant st c i for al a uir inspections. Complete drawing on reverse.sid . N_u Signed X Title: __ Date / FOR DEPARTMENT USE ONLY �- Application Accepted by a zw Date 'T'� 2-2--PI� Area I Y i or Grout Inspection by - Date Final Inspection by�� T/0� Date F Additional Comments: l ❑ 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 w FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH 13-24 tREV,i i K 61 ,O(� ( 1._a3-1 i-` 91- 016 EH 14-26