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I APPLICATION FOR PERMIT .fl. .. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON'AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 LocalHealth District. Job Address �y � r' City Lot Size QPM Owner's Name _C& _X1_r? ZZ= Address Phone 'I 1.• Contractor3/6 Address `�' icense 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 ❑ 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 Well Destruction ❑ Well Diameter Sealing Material (top 501 s Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is II available within 200 feet.) Installation will serve: Residence Commercial_ Other ► Number of living units: _/_ Number_of bedrooms C Character of soil to a depth of 3 feet: Water table depth, SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well /s!}� Foundation Property Line e LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well /? Foundation Property Line f r SEEPAGE PITS Depth ( Size �✓ — Number SUMPS LlDistance to nearest: Well 412� ' Foundation- 0 ~Property Line DISPOSAL PONDS ❑ } ti 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. t _ - 1- 1 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 . I 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 m t all for all re 'red ins ions. Complete dr wing on reve ide. rg Signed X 1 Title: Date: } FOR DEPARTMENT USE_ONLY Application Accepted by `Nil1Date !7-A1—�0X Area rea ( Z 'yam Pit or Grout Inspection by -f Dattef Final Inspection by t Date Additional Comments: `�� zl> [uCo 0` � � L �r � —I �� A�ur✓iZfl�tO Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,-CA 95201' r IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE- PERMIT"NO. +EH 13-24(REV.1/0 5) 4� EH 14-26 �+' S '