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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA �•- Telephone (209) 466-6781 PERMIT EXPIRES'l YEAR FROM DATE ISSUED . (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. Job Address City Lot Size IPM -- Owner's Name ..Address _ fd Ph Cf/ Contractor i Addres s,36, License tT Phon 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 EJ Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation El Domestic/Private ❑ Gravel Pack LlTracy T Dia. of Well Casing Ll Public IYpe of Casing Specifications ❑ �Other __',1;1 Delta Depth of Grout Seal Type of Grout Q'Irrigation �_Approx. Depth "❑tEastern Surface Seal installed by t Repair Work Done ❑ Type of Pump J.c H P. ,_ State Work Done Well Destruction : E71Well Diameter t S6alirng Material (top 501 I Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION{No septic system permitted if public sewer is r` installation will serve: Resi ante_ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth cif 3 feet: Water table depth SEPTIC TANK ❑ -type/Mfg x Ca acit p Y No. Compartments PKG�TREATMEN7 PLT. ❑ IE I I Method of Disposal . rstance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of linesi --%� Total length/size FILTER BED L1Distance to nearest: Well ti An�Faundatian r Property Line !i,r 7.rn SEEPAGE PITS ❑ Depth -size Size / Number SUMPS- Cl Dis'tance to nearest: Well Foundation f DISPOSAL PONDS F71Property Line 1 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.. 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 st call for all requiinspections. Complete drawing on reverse side. y Signed I � Title: Date: _ f_x 14 — U Q 7 � I �.FOR..DEPARTIIR ENT USE.ONLY—' r„ Application Accepted by - •z Date � Area Pit or Grout Inspection byr -final Date -Final Inspect' n by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 'k]'Nl566, Y828-7164 O Tracy •. 56385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT'NO. + EH T3-24 MEV.i/ sl (�c.7 � UA-.- r� "'� ( /EH 1428 7J r ' l 4 � ` '7._