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r E APPLICATION FOR PERMIT SAN JOAO,UIN'LOCAL-HEALTH DISTRICT v 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , 6 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. r%-. Job Address �J ....._ Ch " Lot`Size ��S�r PM Owner's N$AJ 1 f! V Address Phone Contra f 2- ddress T Y 6 License NZ4�Phone L/' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION F1 e PUMP INSTALLATION SYSTEM REPAIR D OTHER ❑ —1 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 rel ❑ ial a [I Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Ztic/Private ❑ Gravel.Pack Ll Tracy Type of Casing Specifications ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout ngation '---Approx. D th ❑ Eastern Surface Seal Installed by k Repair Work Done ❑ Type of Pump H.P._ I State Work Don I( Well Destruction ❑ We11 Diameter Sealing Material (top 501 r ?-T-^-•- Depth—- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is how k available within 200 feet.) Installation will serve:.. Residence_ Commercial Other r ,. Number of living unitsi:, Number of bedrooms Character of soil to a depth'of 3 feet: Water table depth SEPTIC TANK Q ❑"' Type/ Mfg ' i Capacity No. Compartments ? PKG-:TREATMENT PLT. ❑ \e f' Method of Disposal j 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 s SEEPAGE PITS, ❑ Depth Size Number SUMPS i ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ 1 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 'fornia." The appli,a ust call for all required in ions. Co ate drawing on 5w9rse side, J Q Signede �d Title: 5.%� � Date s FOR DEPARTMENT USE ONLY Application Accepted by cm.CJI stnj Date �'�—�yf � Area a Pit or Grout Inspection by Date Final Inspection by ` Date Additional Comments: CXStk 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. -.+ EH 13-24(REV.tit151s EH 14-28