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a _ APPLICATION FOR PERMIT SAN JOAQIUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 3L OERMIT EXPIRES TYEAR FROM DATE ISSUED (Completein Triplicate) �NVIROME��AL HEALTH �ERT'AIT/SERVICES 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. f .i� 22 0 T "" � City Lot Size PM Job Address T ' Owner's Name ""! Address �H �-' Phone Contract '~ 6'Address 0,6oc 7 License NO nit E Phone TYPE OF WELL/PUMP: �� NEW WELL l❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "Y' �-� iINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing LJ Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'7 Public ❑ `Other F] Delta Depth of Grout Seal Type of Grout 'I I Irrigation �p, -Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done " E Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I fNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number o bedrooms / Character of soil to a dept' of 3 feet: Water table depth 0 0� + SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal v Distance to nearest: Well foundation Property Line LEACHING LINE Na- & Length of lines Tal length/size C 2 FILTER BED ❑ Distance to nearest: Well 0 Foundation_/_.. Property.Line M SEEPAGE PITS I,,(i Depth Size ' .33 Nu ber j SUMPS Ll 'Distance to nearest: Well Foundation __.. Property Line s r 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, ander_ 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 compensa- tion laws of California." The applican ust call for re ire o spections. Complete drawing on reverse de. r z,5 )� 6F Signed X ' I� Title: f/ ' s __ _ Date: r I OR DEPARTMENT USE ONLY t l � r„ Application Accepted by iI ^ Date Area Pit or Grout Inspection by Date Final Ins action by ` ZZ, Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 racy 835-'Gfff Applicant- Return all copies�l o: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t U S 1�77 + FEEAMOUNT DUE AMOUNT REMITTED CASH K 0 RECEIVED BY GATE PERMIT NO. INFO +.EH 13-26(REV.)/H 51 EH 16.26 C.•�