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Bt APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.; STOCKTON, CA _ Telephone {209} 466-67$1 �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;i {Complete in Triplicate} 1� - 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. 1 Job Address �"` P��City �► Lot Size�_. - PM Owner's Name 1 1� Address I bum V—]`� Phone i Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 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..-1� TYPE OFAW,•.ELL", __PROBLEM,AREACONSTRUCTION SPECIFICATIONS cr y,,. H' •`""�--•-.-. eco—.— _` �.-- ❑ Industrial ❑ O�e�iBbttom —.DC7 Manteca _ Dia. of-Well'"Excavation ❑ Domest c/P.0_to ❑ Gravel Pack ❑ Tracy _ Type of Casing Specifications ❑ Public ❑ OtLr � ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _pprox. Depth ❑'Eastern Surface Seal Installed by ' . Repair Work Done ❑ Type of Pump H.P. - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 60,T, I DeptV Filler M�terial"le®low 50') � TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION,❑ DESTRUCTION .iNo'septic"syst6rh permitted-if public sewer is l IX available within 200 feet.) i s Installation will serve: Residence J� lommercial_-- Other (�c� Number of living units: " Number&&of bedrooms� _._� Character of soil to a depth�of 3 feet: - f Waterr`table pth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l E PKG. TREATMENT PLT. ❑ Method of Disposal tt i Distance to nearest: Well FouniSatio Property Line LEACHING LINE ❑ N�L4Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size `�I ► -y"Numfier SUMPS ❑ 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 i 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 m t call for require spectio s. Complete drawing on reverse side. Signed �� _ „� Title: Date:' FOR DEPARTMENT USE ONLY Application Accepted by - -_ `-'lDate � h AreaZ,,.,;.,__ s, 1 Pit or Grout Inspection byn y Date' r Final Inspection by Date d Additional Comments: ' A "' ' �, � 7 `�3:� 47r^wy{erX+4CD?C "^!�S/�ec O ❑ Stk 466.6781 ❑ Lodi 369-3621 1 " ❑ Manteca 8'2.3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r ' FEEiL INFO AMOUNT DUE AMOUNT REMITTED l K H RECEIVED BY DATE PERMIT''NO. ' . + EH 13-24(REV.F/e 5) j �"� �J � EH 14-28 f�-61 .� - H, _ ,