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II •<� �� APPLICATION FOR PERMIT ,� t i SAN JOAQUIN'LOCAL�HEALTH DISTRICT p4-y 14 r i ;• 6 1601 E. HAZELION AVE„ STOCKTON, CA RE Telephone 12091 466-6781 1� � I PERMIT EXPIRES i YEAR FROM DATE ISSUED A NOS. (Complete in Triplicate) . , �A♦" Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work fl�reinA� s\14�j5��ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Re u ations of the San.Joaquin Local Health District. _ 4' a 5 Job Address 4/74 S_ IDYL[ a City i Lot Size "{j PM + �� „ Owner's Name ` - Address Phone r ii Contractor Address icense No.V(/ 3�26 Phone 2i r 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 FOUNDATIONi AGRICULTURE WELL OTHER WELL PITS/SUMPS La INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L Domestic/Private 13Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public El Other r EDDelta Depth of Grout Seal_ Type of Grout- ❑ Irrigation ---Approx. Depth' ❑ Eastern Surface Seal Installed by f.i- ' M Repair Work Done �6 Type of Pump �. H.P. State Work Done Well Destruction F1 Well Diameter F j Sealing Material (top 501 Depth III t} Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION` .(No,septic system permitted if public sewer is sf S 4 y,. a .,�. ;y r,,4 t�- available within 200 feet.I Installation will serve: Residence mmercial-- 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 V y�� s� ..t °fie`. f -...�. r sr � PKG. TREATMENT PLT. ❑ I Method of Disposal Distance:tornearest: Well Foundation Property Line ' J) LEACHING LINE ❑ No. & Leng-hr oflines Total length/size FILTER BED ❑ Distance,to nearest: f-Well Foundation Property Line t SEEPAGE PITS ❑ Depth 4 € Size Number SUMPS- r Q Distanceio nearest: Well, . - Foundation_ Property Line- -w DISPOSAL PONDS ❑ � I hereby certify'that I have prepared-this-applice'tion antl-thi3fthe work w'iil-be done in accordance with San Joaquin county ordinances, state jaws, and rules and regulations of the San Joaquin Localj 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." y' Ey The applicant awing on nt must call for al uired�inspectidns. Complete drr arse side. !� Signed X- Title: Date: ��,�M FOR DEPARTMENT USE ONLY r 'Application Accepted by .1 Date Area lln4 Pit or Grout Inspection by -. Date__ Final Inspection by w�Vk Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO. AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE. -PERMIT'NO: + EH 13.24{REV,t/$W EH 1428