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•1 , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /,OT 3 1601 E. HAZEL T ON AVE., STOCKTON, CA0�5k Z_ PERMIT Telephone (209) 466-6781 Z_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 419 (Complete in Triplicate) 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. �/�f Job Address �vf rJ l ��[� Y e/?174C ,p f city /�ix eZ4 /�t Size.. 7 PM[lt:t QCJ�# PhoneOwner's Name Contractor's Name' 'I ��L� nse(No. p z. Z 5�7 Phone l TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E- SYSTEM REPAIR ❑ OTHER ❑ 6 DISTANCE TO NEAREST: SEPTIC TANK4'O 4ffEWER LINES DISPOSAL FLD. PROP. LINE ,5 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing �c/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L O ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f yp out ❑ Irrigation --Approx. DepthE tern Surf ,Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. - - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 �V Depth Filler Material (Below 50') �/i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Q1 available within 200 feet.) {� Installation will serve: Residence_ Commercial_ Other 1j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth w SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 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 ❑ 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." Contractors 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 mu call for all required inspections. Complete on reverse side. Signed Title: _.- Date: G FOR DEPARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by A, DateFinal Inspection by 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 INFOC,,WRECEIVED BY DATE PERMIT"NO. { + EH 13-24 JAEY,10/831 0 �n III. s�rs EH 14-28 - 1 -1