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f APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11,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: Job Address ,• t City Lot Size PM Owner's Name ft 1 j*'l t' �� fr ¢tl�ess Fi _ Phone I/V-,; - i Contractor G ., Address License No. Phone TYPE OF WELL/PUMP: Z9 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO AL•FL-M PROP_ LINE FOUNDATION AGRICULTURE WELL ----6TH WELL PITS/SUMPS F INTENDED USE TYPE OFA WELL ' PROBLEM AR NSTRUCTION SPECIFICATIONS ❑ Industrial ... 11 Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �,[ i i 1 Public fl Othe 171 Delta Depth of Grout Seal Type of Grout .I pprox. Depth I I Eastern Surface Seal Installed by _ I Irrigation �Repair Work Done ❑ Type of Pump H.P. State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material Itop 501 t .. Depth Yf Filler Material lBeVv 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I. I REPAIR I ADDITION'V DESTRUCTION (No septic system permitted if public sewer Other is- j available within 200 fee .l I Installation will serve: Residence t _ Commercial___ (�/p, Number of living units: Number of bedrooms t �""l✓tX t Character of soil to adepth 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 e f LEACHING LINE ❑ No. & Length of lines -Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1A Depth Size Number " SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a 4 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 Di1trict. Home owner or licensed agent's signature certifies the following: "1 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:"l certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's cornpensa- ' tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. i # Signed K_ Title: '"1 Date: Z4, — " - FOR DEPARTMENT USE ONLY { �-�v Agp�icatk),0 Accepted by �'_ �, _'� . _ Date ' 772 Area ' Pit or Grout Inspection'by .Date Final Inspection b Date Additional Comments: ' ❑ Stk 466.6781 ❑ Lodi 369-3&21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �d ��$�� /r W-re Applicitn!- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT NO. ♦.EH 13-24 IREiV.1/N 51 EH 14.26 r . ..