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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Co44 wq S 4-o o 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I{2 (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. , p J a Job Address a City s of Size PM 4 i � a J � / l� Owner's Nam I IN Address _�/�� _'fJ/j7�i Phone Contrac o- C Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 Dia. of Well Excavation Dia. of Welt Casing D Domestic/Private ❑ Gravel pack ❑ Tracy Type of Casing Specifications j ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal - Type of Grout � ❑ Irrigation --6p-r x'Deptti—L7'Eastetn' ,, , -Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop�011 Depth Filler Material (Below 50'} TYPE OF SEPTIC;WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION XMo septic system permitted if public sewer is 4 -available within 200 feet.) Installation will serve: Residence_ Commercial_ Other # 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 11 Capacity - No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I .Size Number SUMPS ❑ Distance to'.neyarest: Well Foundation Property Line DISPOSAL PONDS. ❑ I f 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 L_offal Health District. Home owner or licensed agent's signature ce"rtifies 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_imthe performan�e.of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." �" `+ Z •A .,,*_ ^ ,:y The applicant mu call for all ire inspections. to drawing on reverse side. SignedTitle: Dater FOR DEPARTMENT USE ONLY Application Accepted by Date 5"�--W-46 s Pit or Grout Inspection Date Final Inspection by v U V-) Dater 3 Additional Comments: f S• L. n •..e ❑ Stk 466-6781 ❑ Lodi 369-35111 ❑ Ma ca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2DD9, Stk., CA 01 V FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO + EH13-24(REV. EH 1426 f p �b^ J