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r APPLICATION�.FOR PERMIT SAN-JOAQUIN LOCAL HEALTH DISTRICT "iC7Y 'r 1601 E. HAZELTON AVE., STOCKTON, CA (.. Telephone 12091 466-6781 PA, c vie- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v i (Complete in-Triplicate) r Application is hereby made to the San-Joaquin Local Heatth District for a permit to construct and/or install the work herein dekcr d� 'T s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 186'1 for well/pump and the Rules and ulatiofla9'F �Joaquin ! Local Health District. ' _ ��13''"��1� t v Job Address L L City Lot Size PM Owner's Name /O/T[, Address Phone Contractor's Name r '.icense No. 9a Phone C5VS__//4T5 i TYPE OF WELL/PUMP: NNW WELL.-/! WELL REPLACEMENT`A DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ a l t . .. DISTANCE"TO-NEAREST: SEPTIC TANK -Id0 / SEWER LINES, DISPOSAL`FLD: n� � ' POOP:LINE` FOUNDATION AGRICULTURE WELL OTHER WELLS'�,� `sPITS/SUMPS 4 "" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �z ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation ff Dia. of Well Casing VDomestic/Private Gravel Pack +/Tracy Type of Casing eye, Specifications . ❑ Public ❑ Other ❑ Delta Depth of Grout Seal «�� _- Type of Gro L . El Irrigation --Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction X Well Diameter- Sealing Material (top 501 Depth �Sl1"6a Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS Y f Depth Size -- Number- -•� - �'"'-"-"� 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 i 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." I The applicant st call for all required inspections. Complete drawing on reverse side. Signed e Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date fZr�� Area C/ Pit or Grout Inspection by ate ~' Final Ins tion by Date + Additional Comments: i�z ❑ Stk 466-6781. ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 835-63BErk Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT INFO CASH +EH 13-241REV.101831 • Op . EH 14-26 �a