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/ f APPLICATION 'FOR PERMIT ( SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL i ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED { (Complete in Triplicate) t 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�/�] � $ . (`� Gt trF City �arGLfe Lot Sized ° � tJ PM �J Jab Address Owner's Name d'1 L G/• L.frl 3A '�4ddress �tirl ISI r Phone1 I i Contractor Se—` F Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTION ❑` ,1 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casirig Specifications r�1 !F1 Public n Other lJ Delta Depth of Grout Seal Type of Grout l3 I 1 Irrigation —Approx. Depth I I Eastern Surface Sea! Installed by a Repair Work Done ❑ Type of Pump H.P. = State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50 Y Depth Filler Materia! .(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i.l DESTRUCTION l I (No septic system ermitthd'if public sewer is , / available within 200 feet.) Installation will serve: Residence V Commercial Other Number of living units: _ _ Number of bedroo ` } Character of soil to'a depth of 3 feet: Water table depth SEPTIC TANK t ❑ Type/Mfg I JP Capacity No. Compartments PKG. TREATMENT PLT. ❑ / / Method of Ds orsal 1 ' Distance to nee res; Well Foundation _ Property Line j S� 'r 01 INE No. 11 Len th of lines T tal length/size Z or I LEACHING L g p FILTER BED ElDistance to nearest: Well Foundation ...__. Property Line ._ SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 l 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." The applicant ust call for all require inspec i ns.00orriplete drawing on.reverse side. r} Signed X J Title: (.t " - Date: —/.`' — 61 61 FOR DEPARTMENT USE ONLY Application Accepted by _ Date , v Area j 7� c�6r Pit or Grout Inspection by Date Final Inspection b ' Date Additional Comments: ❑ Stk 466-6781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH //f +.EH13-24)REV.i/n51 c�v /(/ V7 EH t4-29