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f� k f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL*HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE.,-STOCKTON, CA � ' Telephone (209) 466-6781 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED �,.. N �.y (Complete in Triplicate);,. �r 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.' ,�,,} �� l ,.r'+ .� - .�: _ �. .rgj,c, r ,�; x1S ', -:,. 9 Job Address b /V "' ! 1! / 'o SD`?� a�"J Cit w Lot Size PM ' �wner's Nam �� _ - �/ - - 5 Address e fi Phone ~��7` Contractor ! Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E OTHER ❑ r DIS ANCE TO NEAR NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARliA__C0NS I ZBUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well x n- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin 9 - - Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T pe of Grout ❑ Irrigation _-4pprox Depth ❑ Eastern Surfa a,Seal Installed by' Repair Work Done ❑ Type of Pump H.P., State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAiR/ADDITION ❑ DESTRUCTION 9qNo septic system permitted if public_ sewer is 1 ailable within 200 feet.) Installation will serve: Residence Commercial_ Other L 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:` Water table de th Ili P SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ E Method of Disposal Ii Distance to nearest: Well Foundation_..Property-L-ine- LEACHING LINE" ❑' No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � t SEEPAGE PITS ❑ Depth Size Number .l � I SUMPS ❑r-Distance to nearest: Well ` Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared thisF 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:1 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 Cafifotnia." The applicant mus II for all r ed inspections. Complete drawing on reverse side. �( Signed X Title: Date R DEPART ENT USE ONLY \ Application Accepted by Date _70Area Pit or Grout Inspection by Date Final Inspection by r/� �" \ Date�� Additional Comments: t (�;,/% JI �f ❑ Stk 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 -� � F^' INFO ' AMOUNT pUE "� AMOUNT REMITTED- RECEIVED-BY`�` �OATE -" PERMIT NO. f► l + EH 13-241REV.iiHs1 ,��' .TUU -3 g ( 1�1 ��