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' APPLICATION FOR' PERMIT � �� SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � �Y $ � � Teiephohe (209) 466-6781 1 PERMIT EXPIRES 1'.YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES ; h District far a permit to construct and/orinstall the work herein described. This application is Application is hereby made to the San Joaquin Local Healt 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. City Lot Size PM Job Address � lr Address ��)C�Pfione Owner's Name ! Address ✓r License Noti ,'� !J Phone_ - Y•? Contractor a ` ll TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR'. OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 13 Industrial ❑ Open Bottom 13 Manteca Dia. of Well Excavation Dia.rof Well Casing Type of Casing Specifications 1 �Domestic/Private ❑ Gravel Pack C1 Tracy 9 j FI Public % f 1 Other i 1 ❑ Delta Depth of Grout Seal Type of Grout fl I 1 Irrigation _..Approx; Depth 1'1 Eastern - Surface Seal Installed by Repair Work Done (4 Type of Pump H.P. State Work Done' " Well Destruction ❑ Well Diameter Sealing Material (top 501 -- Depth Filler Material (Below 50'1 S TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feeL1 , a 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 Y SEPTlC TANK [3Type/Mig Capacity No. Compartments PKG. TREATMENT PLT. 171, ", "� s` Method of Disposal ^ I : 'Distance'to nearest: Well afoundationY_ .. WProperty_Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tc nearest: Well Foundation Property Line t Number SEEPAGE PITS LI I"�bepth ( -" Size r SUMPS ❑' Distance tonearest: Well Foundation Property Line ( DISPOSAL PONDS ,� ❑ 'X... ._; 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§trict. 4 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 t employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature p 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 ap nt must 11 for all require ctio . Co late drawing on r v se side. y Signed X Title:Yw f Data: FOR DEPARTMENT USE ONLY Z� Application Accepted by Date /� Area Pit or Grout Inspection by Date Final Inspection by Aate r Additional Comments: ❑ Stk 466-67111 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH r - , +.EH 53-24 rREV.r/B5') �� . 5�� ao EH 14-26 I. "�