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APPLICATION FOR PERMIT r � J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �yJ _ (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 District. , f4ai �'le,,,..i .,� Job Address City Lot'Size I PM wn is Name -Add - 7 0 e rens "Phone r� / 1 Contractor r ess ! License No-i F Phone YA TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ OISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DIS PROP. LINE f. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECIFICATIONS f r El Industrial C1 Open Bottom ❑ M #Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation rax. Depth ❑ Eastern es-Surface.Seal_installed-by--- ---- Repair Work Done pe of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 I { t Depth ` 4 "' �� Filler Material {Below 501 ' TYPE OF SEPTIC;WORK: NEW INSTALLATION ❑ REPAIR/ADDITION, DE TRUCTION ❑ (No septic system permitted if public sewer is gavble within 200 feet.)Installation will serve. Residence_ Commercial— Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r '.Water table depthM SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a --'PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line EACHING LINE ❑ No. & Length of lines Total length/siz'e' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS . ❑ Depth Size Number SUMPS ❑ _Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �' I I hereby certify that I have prepared this application and that the work will be done in accordance with gan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I _ 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 applican ust call for required i spections. Complete drawing on reverse side. �s,°+ Signed - s Tide: CJS:..ff d � Date: € .FOR DEPARTMENT USE ONLY Application Accepted by c�-:_ Date i Pit or Grout Inspection by _Date Final Inspection by Date a77 u c Additi nal Comments; ❑ Stk: 4666781_ ._❑ Lodi 369,3621 0 Manteca .8237104 _❑Tracy.,,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 -,s- CCASM� w. RECEIVED BY DATE PERMIT NO. + EH1}241REV,1/851 EH 1428