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APPLICATION FOR PERMIT j' ��fi SAN JOAQUIN- LOCAL HEALTH DISTRICTa, - IF i. d, i IN 1601 E. HAZELTON AVE., STOCKTON, CA SAN Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F`..faN LO'� (Complete in Triplicate) I-� AL A,-T�i DISTF?!C T 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 C, Ci of Size PM 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 21� is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe in such m nner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature certifies thef ong: "1 ce that in the perfo ance oft work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o California." The app)' ant or I required dr Ing on rave,4wr Signed Title. Date: �. 0 - FOR DEPARTMENT USE ONLY /? Application Accepted by Date Area x Pit or Grout Inspection by Date Final Inspection by P'h..� .�,�.N.� Date Additional Comments: ❑ 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 EH 1324 (REV. 10/83) EH 1126 FEE INFO - - - - b I on rltn �� ' Owner's Namer Phone - I�j 2 3 7� V16 12 Z1 Contractor's NameA"'itcense No. / Phone - TYPE OF WELL/PUMP: NEW WELLI ELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind trial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing C�J"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Ea ern Surface 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 ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms 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 length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 21� is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe in such m nner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature certifies thef ong: "1 ce that in the perfo ance oft work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o California." The app)' ant or I required dr Ing on rave,4wr Signed Title. Date: �. 0 - FOR DEPARTMENT USE ONLY /? Application Accepted by Date Area x Pit or Grout Inspection by Date Final Inspection by P'h..� .�,�.N.� Date Additional Comments: ❑ 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 EH 1324 (REV. 10/83) EH 1126 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' 4 q5 1 -5-9. -34-19