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'r I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA € Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 11 Job Addressw City Lot Size v` PM ig a 0-77 Owner's Name dress Phone i Contractor 'I Address License No. Phone + TYPE OF WELL/PUMP: V11. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F POOP. LINE FOUNDATION AGRICULTURE,WELL WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications — M Public r f.-1 Delta Depth of Grout Seal Type of Grout . i I Irrigation =_Approx. Depth I 1 Eastern Surface Seal Installed by Repair Wor one L1 -Type of Pump H.P. State Work Done Well struction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION I INo septic system permitted if public sewer is II available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms F 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 lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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 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 qt, nce of the work for which this permit is issued,i shall employ persons subject to workman's compensa- tion laws of Califo nia." 4 f Th applica m t call for it equired Co ete drawing on reverse side. g Signed X Title: 1��--r�za/J J. Date: / is FOR DEPARTMENT USE ONLY Application Ac pled by Date _Z Z Area I Pit or Grout Inspection by Date s y Final Inspection D to Additional Common 111fZhMC1C, ❑ Stk 466-6781 ❑ Lodi 3696621 ❑ Mantec 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,:P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH 43-24{REV.Fix 51 �c �,�U o - \`�q.. I Dn T "�`9 � 8 ) '3S EH 14-26 l -y�7 �1/ w