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nAPPLICATION FOR PERMIT , SAN JOAQUIN LOCAL.HEALTH DISTRICT �� 1601 E. HAZELTOIV AVE., STOCKTON, CA 1" Telephone (209) 466-6781 } , PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED .t: (Complete in Triplicate), w. ' ..a .y ..F 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. oor Job Address r City r^ Lot Size PM. Owner's Name C L Address yoaC [.ju c Phone i Contractor r Address License 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 FOUNDATIONN _ _- AGdkCULTURE WELL OTHER WELL PITS/SUMPS li 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 Ll Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern (( Surface Seal.Installed_by� Repair Work Done ❑ Type of Pump v 1 H.P. State Work Done x Well Destruction ❑ Well Diameter f 's Sealing Material (top 501 Depth - --- -Filler,Material (Below.50')r--•-- 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 s^ r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: l Water table depth SEPTIC.TANK ❑ Type/Mfg Capacity t No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well - Foundation Property Line `V LEACHING LINE ❑ No. & Length of lines Total lengfh/size FILTER BED ❑ Distance to nearest: Well Foundation 'Property Line r 2. SEEPAGE PITS ❑ Depth Q 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 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." ff The applicant must II for all required i ions. Com to drawing on reverse side. i• ;- IEt` Signed Title:- -"- y t Date: , F DEPARTMENT USE ONLY F, �^iccepted by D,,.,y-",,-" Application Aate Area Pit or Grout Inspection by Date Final Inspection by r, Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 i 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 ASH RECEIVED BY DATE PERMIT'NO. INFO -r EH 13-24(REV.!./H5) ve �7-l6Q EH 14-28