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rt APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,-.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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/ um and the Rules and Regulations of the San Joaquin PPP Local Health District. p p t Job Address I 4 (9 U K Q City Lot Size PM A Owner'sName M dress4� �1�4,�r.,,� Phone .g Contractor 1 Address_«Z� t – ^ f k� —License No. Phone TYPE OF WELL/PUMP: IP NEW WELL LlWELL REPLACEMENT ❑ DESTRUCTION ❑ - -PUMPPINSTALLATION-❑— --- —SYSTEM-REPAIR`❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ii ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other LJ Delta Depth of Grout Seal Type of'Grout ❑ Irrigation J4pprvx. Depth ; ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump - H.P. f State Work Done_ Well Destruction ❑ Well Diameter Sealing Material It 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW(INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ill vailabte within 200 feet.) ' Installation will serve: Residence— Commercial_I Other Number of living units: iwNumber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El III Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:` Well Foundation Property Lin e j LEACHING LINE ❑ No.r&Length of lines Total length/size FILTER BED ❑ Distance to nearest:. - Well Foundation Property Line / SEEPAGE PETS ElDept"rh Size Number } SUMPS ❑ Di sta`nce to nearest: Wel! Foundation Property Line DISPOSAL PONDS ❑ Iil r I hereby certify that I have prepar6d 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's corn nsa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. X Signed I f 49w e Title: <� Date: FOR DEPARTMENT USE ONLY ` t" Application Accepted by a Date Area Pit or Grout Inspection by + Date Final Inspection Y� Date Additional Comments:—W-? ki 6 I6 5 as� brrc. 110CIQ;� c� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca _823-7104 ❑ Tracy 835 6385j/j�q lRr Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., :P.O. Box 2$d9, Stk., Cfl(95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO: INFO CASH { EH R 1REV-1/ 51 UU EH 14-19 �[7 �