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P APPLICATION FOR PERMIT Es� I i i SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., .STOCKTON, CA ND l►�1 ,�, Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) CAD 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/pump and the Rules and Regulations of the San Joaquin Local Health District. . �fX i _. Job Address Cit Lot Size � PM Ow is Name a /� ddress .4leC��j +�-Q •+` Phon I r "c l Address "� License No: , Phone TYPE OF WELL/PUMP,:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ,TYPE OF WELL PROBLEM AREA mCONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta" 'r.Depth of Grout Seal Type of Grout LlIrrigation ___4prox. Depth E] n Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50) Depth) Filler Material (Below 50') TYPE OF SEPTI'C WORK:, NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 570 septic system permitted if public sewer is (� �•', avaib within�� Installation will serve: Residence— Commercial_ Other !eC� Number of living units: Number of bedrooms f s r Character of soil to a depth of 3 feet: I Water table depth I SEPTIC TANK ❑ Type/Mfg `Capacity No. Compartments PKG. TREATMENT PLT. ❑ i t 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 f Size I Number i 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of lifornia." Thea Iic must call for all r ired'ins " pp pections. Complete drawing on reverse side. Signed j i � Title: Date: OR EP4aTMENT USE ONLY [ 4 Application Accepted by Dater (n-a 87 Area # ` Pit or Grout Inspection by--- --- Date' Final Inspection by Datet7 Additional Comments: ''<. r�-VI D L� S P + S-73 i ❑ Stk 466-6781•- ❑ Lodi 369-3621 ❑ Manteca 823-7104f .❑ Tracy 835-6385 Applicant - Return_ .,all copies to: Environmental Health Permit/Services"I601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. + EH13-24 4REV.I/a 5) it - EH 14-28 ✓ 4 1 6 r 1 J