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Ii ILII APPLICATION FOR PERMIT I° SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA it Telephone (209) 466-6781 I� I� PERMIT EXPIRES 4 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. 1852 for weillpump and the.Ruies and Regulations of the San Joaquin Local Health District. y�r Q£1 II:iV. �`'j IJLj . � Cit Job Address Lot Size PM14-1 H._9i 3 f� 1� 78 Owner's Name � � �• � Address - - - Phone _5 ' ti A Contractor ddress License No. Phone_ TYPE OF WELL/PUNNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P: PLIMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I . 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 i f ❑ Industrial ❑'Open Bottom ❑ Manteca Dia.,of Well Excavation Dia. of Well-Casing ❑ Domestic/Private ❑(Gravel Pack ❑ Tracy Type of Casing Specifications } I r 1"1 public f 1(Other Fl Delta Depth of Grout Seal Type of Grout-- I rout _.i I Irrigation -�-_,,_Approx. Depth I I Eastern Surface Seal installed by � i" H,P, State Work Done Repair Work Done 11 Type of Pump JWell Destruction ❑ Well Diameter Sealing Material (top 501 - Depth Filler Material {Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is -tx ,f� 11 available within 200 feet.) J Installation wl ;serve: Residence X_ Commercial_ Other E i Number of living.�nits: _. Number of a rooms O Character of soil'to-a depth of 3 feet: � Water table depth SEPTIC TANK 4�� Type/Mfg Capacity _.y �i— No. Compartments 01- PKG. TREATMENT PLT. ❑ f f Method of Dispysal Distance to nearest:—,.-Well_. �4 Foundation �� Property.Line LEACHING LINE I�No. & Length of lines - ,Total lerigth/size_� d - FIL7ER BED '❑!� DistarLce to nearest: We[I Foundation'_ 10 Property Line — ) ix"SEEPAGE PITS -� f Depth Size TA'/ Number r �. :;:. SUMPS ,-_ Y Eli Distance to nearest: ".,Well Foundation Q Property Line `-i•1, fr DISPOSAL`PONDS- _ ❑� i 4I hereby certify that I have prepared this application and that the work will be done'rn'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 compensairon Laws of California."Contractor's hiring or sub-contracting signature. t[ i' certifies the follow @: "I certify that in the performance of the work for which this is issued, I shall employ persons subject to workman's compensa- 1 'tion iaws-of•Califoinia-" Y The applicant st call for all required inspections. plete drawing on reverse side." . Signed X [/t `it/" _ ✓ Title: Date: FOR DEPARTMENT USE ONLY CeC Application Accepted by Date Area Pi or Grout Inspection byU"T ate Final Inspection by ate Additional Comments. -�F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO i p d +.EH 13-21 fREV. /R5r � � -t �3 EH 14-28