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i APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA II 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/or install the work herein described. This appliclation 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. I ', Job Address A&4_ CA] ILCity of Size PM „�1a� Qf c� Owner's Name Address l [ W• "" - _ . /.T Phone Q` w Contractor Address ► License No. Phone Cl4b` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ,f/J PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 41 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing I. © Domestic/PrivateGravel Pack C1 Tracy Type of Casing _ Specificatiflns M Public F 1Other F7Delta Depth of Grout Seal � � - Type of Grout 4 e 11 Irrigation ,, n Approx.Depth I I Eastern Surface Seal Installed by 1 Repair Work Done U Type of Pump H.P. State Work bone_ Well Destruction ❑ Well Diameter Sealing Material (top 50') ko Depth Filler Material f6elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is v availablewithin 200 feet.) Installation will serve: Residence—�.- Commercial_ Other r Number of living units: Number of bedrooms i 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 ` I Distance to nearest: Well Foundation Property Line { LEACHING LINE ❑ No. & Length of lines x Total length/size FILTER BED. ❑ _Distance to nearest: Well Foundation Property Line F SEEPAGE PITS I I Depth i Size Number l SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ l 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-"r-' j employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractingsignature, j certifies the follow( g: ertify 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 Calif ni The applicant t r If squired inspections. Complete drawing on Signed X f Title: Date: i I� �r/� r . { FOR DEPARTMENT USE ONLY i Application Accepted byDate Area i I ' Pit or Grout Inspection by i= Date Final Inspection by Date Additional Comments: 1 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. tEH13-24SREV.tinsl �` lll.aay�l 11 EH 114-26 �.,.� •v-—_— I "r �7 tP ' -