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_ t APPLICATION FOR PERMIT II SAN JOAQUIN LOCAL HEALTH DISTRICT 1 ;j 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephone (209) 466-6781 �AO PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . I II (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"Arid Regulations of the San Joaquin Local Health-District. " r rt Y v °Rr'x r Job Address �/ 713 1L:✓'52Ui7d ✓� - City Lot Size.: PM. I; 'V Owne?s Name //I � I��All Address Phone Contractor �]�r f Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION © II I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL —PROBLEM AREA —CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing I' e of Gasin Specifications El Domestic/Private ❑ Gravel Pack ❑ Tracy Typ g ❑ Public T ❑ Other ❑ Delta Depth of Grout Seal Type of Grout l El-Irrigation ---4pprox,..Pepth , ❑ Eastern Surface Seal Installed by 13 11 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 } Depth I Filler Material (Below 50') (' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO !No septic system permitted if public sewer is 0 } available within 200 feet.) 41 Installation will serve: Residence '`! Commercial Other Number of living units: Number of bedrooms I r Character of soil to a depth of 3 feet, Water table depth SEPTIC TANKType/MI Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r I Distance to nearest: Well Foundation Property Line F II LEACHING LINE O No. & Length of lines ' Total length/size FILTER BED ❑ Distance,to nearest: Well Foundation Property Line II SEEPAGE PITS ❑ Depth Size Number SUMPS .❑ Distanceto nearest: Well Foundation Property Line I 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 i rules and regulations of the San Joaquin Local Health District.. I 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." The applicant must call for all r wired'inspect Complete drawing on verse side. eq Signed X Title: Date: 1 FOR DEPARTMENT USE ONLY ' rt Application Accepted b Data _�� s Area 0 Pit or Grout Inspection b p� Date Final Inspection by Date Additional Comments: EJ Stk 466-6781 E] Lodi 3693621 ❑ Manteca 823;7104 '❑ Tracy 835-6385 ss ��'TAG Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 li° i �. FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV35 �s• �cl � EH 14-25 _ -:I4