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` APPLICATION FOR PERMIT$ , 4� y �o SAN JOAQUIN LOCAL HEALTH DISTRICT V� PAYMENT x a, 1601 E. HAZE T ON AVE., STOCKTON, CA R E C E I V EI) Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Jul (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wokNWR i6MTA1..l' 5,AiHi4. is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and NTI%pf\1�Cnn Joaquin Local Health District. Job Address /�i /L _T City- Lot Size - Y � PM Owner's Name �� '�7 Address Phone ek Contractor hJ VIC Address License No3 05-2 Phone 3 t ZY 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 _ I I Irrigation — Approx. Depth l I Eastern Surface Seal Installed by _ �] Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION I I fNo septic system permitted if public sewer is I ✓ available within 200 feet.! installation will serve: Residence_ Commercial— Other Number of living units: Number of b rooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T e/Mf ��✓l.Gr 1 V I YP 9 � Capacity No. Compartments �— PKG. TREATMENT PLT. ❑ r21. 7. { Method of Disposal r k� Distance to near i:-�7-t Wel Foundation Property Line I LEACHING LINE'. [P--No. & Length of lines 2 �� dr Total length/size FILTER BEP p Distance to nearest: Well_../._[1O f Foundation Property+1+ ihe'1��r v SEEPAGE PITS IDeptii` f Size ee Number SUMPS Ll Distance to nearest: Well r �f s�- Foundation Property Line DISPOSAL PONDS ❑ ` ! "' `s. I hereby certify that I have preparsd-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#o become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify thA 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 applicanmus call for all require ins ctions. Complete drawing on reverse side. Signed X__, a Title: Date: r FOR DEPARTMENT USE ONLY t Application Accepted by Date v �A Area 1 Pit or Grout Inspection by Date Final Inspection by 0.,f a Date`" Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y INFO FEE AMOUNT DUE AMOUN'T`RE7MITTED CASH RECEIVED BY DATE PERMIT NO. * 15H 1 3-24{REV.i/x 5) £H 14-29 !d