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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ��f �f J�, r� F 1601 E. HAZELTON AVE., STOCKTON, CA ` (JI Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E !(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 Districts f 1 �A Job Address 1' �.o ii {� City f V Lot Size c pM Owner's Na AddrepssT 5 o Phone �o f Yt� _Q ; Contractor � ��KAAddr�' License N� �?� Fhon �' b! TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ��. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK AVa SEWER LINES DISPOSAL FLD/_!J7_—O PROP. LINE FOUNDATION `B 4 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ❑�Indust�ial pen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing Ir�'oOmestic/Private ❑ Gravel Pack ❑ Tracy Type(5i'Casing Specifications F1 Public Ll Other H Delta Depth of Grout-Seal Q Type e o r _ _ I I Irrigation __Approx. Dept I astern 5u ce Seal Installed by Repair Work Done L7 Type of Pump" t H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'I j Depth Filler Material (Below 50') p I TYPE OF SEPTIC WORK; NEW INSTALLATION 1.1 REPAIR/ADDITION I i DESTRUCTION I 1 INo septic system permitted if•public sewer is Q f available within 200 feet.) f Installation will serve: Residence_ Commercial. Other " Number of living units: Number of bedrooms Character'of soil to a depth of 3 feet: ` e Water table depth SEPTIC TANk ❑ Type/Mfg Capacity Na. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line --------- LEACHING-LINE. ❑ No.-& Length of lines Total length/size . FILTER BED ❑ Distance.to nearest: Well Foundation Property Line SEEPAGE PITS C I 'bepth Size Number o SUMPS Ll 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 work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for all required inspections.` plate drawing on reve a side. #} Signed X y Title: Date: }r "_FOR DEPARTMENT USE ONLY Application Accepted by 6A Date Area s Pit or Grout inspection byn by Date � Data +Z [� - �3� Final Inspectio ili Additional Comments: / 0 Stk 466-6781 . ,❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 s Applicant • Return all copies to: Environmental.Health'.Permit/Services i60r1 E. Hazelton Ave„ P.O.-Box 2009, Stk., CA 95201 ' - FEE AMOUNT DUE AMOUNT REMITTED s INFO RECEIVED BY DATE PERMIT-IVO. r EH 13-24(REV.1/n51 EH 14-20 I r