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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I_TON AVE., STOCKTON, CA 1601 E. HAZE k Telephone 12091 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x i (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. i _} e t� {�L� _ /�� � Job Address �o / �•_ +� �.s f!`�1�r. City Lot Size PM ! Owner's Name 0 (' -� Address 9-15 S Phone i Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I 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 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca --J Dia='of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑•Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout El Irrigation �pprox. Depth C1 Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 vv f1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION D (No septic-system permitted if public sewer is m available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ :# Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 11Distanceito nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 tKat"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:"1 certify that in the performance of the wo k for which th)s permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant m call fo Ire d i pact o . Co to drawing on revers side. Signed ` Title: Date:' 7—Z3 FOR DEPARTMENT USE ONLY ., Application Accepted by Date r Area Inspection b Dat Pit or Grout Inspection by - Date Final Ins pe Y �tr Additional Comments: +� ❑ Stk 466-6781 ❑ Lodi- 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.63135 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 A RECEIVED 6 DATE PERMIT"NO. INFO �ff Y = r.X10oa ion° , oP �-7 =s � ,+EH.13.24[REV.101831 '- s EH 1428=+