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r. i APPLICA',,1ON FOR "PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL.TON AVE-, STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_i i"'=° i"`r'I• °1 fi" "` `' I_hY (Complete in Triplicate) Py." Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instali'the work herein described. This applicaL;n is made in compliance with San Joaquin ounty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaqu n Lccal Health District. f Job Address City Lot Size PM 17 r�i" f�✓ Phone r a / rn ddress Owner's Name Ar c? Contractor ,j Address ''P G ' License No. - Phone/ µ� TYPE OF WELL/PUMP: r4EW WELL ❑ WELL REPLACEMENT 11 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 OFfWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ M`3nteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public n Other F1 Delta Depth of Grout Seal f Type of Grout I i Irrigation � Approx. Depth f I Eastern Surface Seal Installed by Repait Work Done [_1 Type of Pump !f H.P. State Work Done We@ Destruction ❑ Well Diameter Sealing Material Itop 50'i r Depth Filler Mater-sal (Below 50') _._ i TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it 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. 0 1 Method of Disposal_ Distance to nearest: Well Foundation Property Line r.. k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CJ Distance.to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Size _ Number SUMPS LI 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 thatinthe 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 signa! a, ' certifies the fall o ing: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Ca f rnia." The applic nt t call for all re ed Am5pens_,,Complete drawing on,evrse side.Signed XTitle: �' C J Date: [ I FOR DEPARTMNT.USE ONLY�%/ Application Accepted by Date / Area Pit or Grout Inspection by ,Q / [� Date �} ,C. Finai Inspection by Date Additional Comments: ku r" ry /7�' Imo'4'ii/� k re., i 14AW / /�✓/ , �� ❑ Stk "466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 41- '4?--(--' ^ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` -Gd " INFO CK FEE AMOUNT DUE- AMOUNT REMiTTEO CASH RECEIVED BY DATE PE MIT"NO. EH 13-24(REV.7/r1 51 C4 S F` EH 14.26 �, � .' �..��