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°„- . APPLICATION FOR PERMIT 4-'� SAN JOAQUIN LOCAL HEALTH DISTRICTLF 1601 E. HAZE'"TON AVE., STOCKTON, CA 4f�t � ��.•y. }� ', �` ' Telephone 4209? 466-6781 ..- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED`''r�I (Complete in Triplicate) ' TRIC ' 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. Job Address / City Lot Size PM r Owner's Name • A�� -`�i , , Contractor's Name Frr License No.C %—6 r 173 Phone `+ I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ ' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r DISPOSAL FLD. PROP. LINE i "tom FOUNDATION AGRICULTURE WELL OTHER.WELL.:PITS/-SUMPSv---- INTENDED USE_' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ElOpen Bottom 171 Manteca' Dia. of Well Excavation Dia. of Well Casing Cw7 lnlestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public LD Other ❑ Delta Depth of Grout Seal Type of Grout 1-1irrigation /_-4pprox. Depth El'Eastern Surface Seal Installed by Repair Work Done E� Type of Pump H.P._ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑' DESTRUCTION ❑ (No septic system permitted if public sewer is J % available within 200 feet.) het 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 4r f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS-7-1.:.........� 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 th quin Local Health District. Home owner or licens agent's sign ture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person i such manner as o become subject to wor n's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follow' g:"I ce ify that' the perform c o the o for wh' this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Cali rnia." The applicant st c fired ins t' o to drawl on reverse si Signed e: Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by WA��t-C440LDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M 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 CASH RECEIVED BY DATE PERMIT'NO. 41+ EH 13-24(REV.10183) EH 1428