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>� � APPLICATION FOR PERMIT SAN JOAQUIN•LOCAL HEALTH DISTRICT 4> 1601 E. HAZE T ON AVE, STOCKTON, CA Telephone (209) 466-6781 (hp i PERMIT EXPIRES 'I 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 fJob Health District. ddress City . of Size PM r'sNameY4I"`��l�i r� Ad ressPhoneactor_ �L�/ . .---- Address�2/7 J // ��"' '" Y License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ k Well Destruction 0 Well Diameter Sealing Material (top 501 Depth + Filler Material (Below 501 c: A TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is $- �- - available within 200 feet.) Installation will serve: Residence± Commercial Other Number of living units: Number of bedrooms Character of soil to a dep h of 3 feet: t•� Water table depth SEPTIC TANK � Type/Mfg Capacity /""L No. Compartments PKG. TREATMENT PLT. Eli Method of Disposal ` Distance to nearest: A Well [ Foundation Property Line - i �,.. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i c _- SEEPAGE PITS Depth CA46PSize Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! 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. r- ; Homeowner 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 cert ifies 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 m st call for all required inspections. Complete drawing on reverse side. / Signed X '��^- t� !/�1J�.� O�iTitle: _i Date: b F7 FOR DEPARTMENT USE ONLY u Application Accepted by Date 1" Area Pit or Grout Inspection b j _i1 _t Date /Final Inspection by Date Additional Comments: y �&'q-7 / . _ - ❑ Stk 466-6781 ❑ Lodi 366-3621 ❑lManteca 823-7104 - CDTracy 835-6385, Applicant- Return all copies to: Environmental Health Permit/Services. 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE --'AMOUNT REMITTED K RECEIVED BY DATE PERMIT•NO. B� a EH 13-241REV. 57r � 44 4-7 EH 1428 - (f / r. t