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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �-' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f PER EXPIRES 1 YEAR FROM DATE ISSUED 11r•, (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. 1562 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address �Q.f �--i C�LcJT�-ci (y City. Lot Size PM As Owner's Name , ✓►� (:Address L+r- Phone "` 7 1`� d i f Contractor's Name '�' � License No./ 1-3 T Phone & — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1a �� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i )NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications ' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i * ❑ Irrigation ;' --Approx.rD�*� �/❑ Eastern Surface Seal Installed by Repair Work Done 2" Type of Pump v ;H.P._� State Work Done L Well Destruction ❑ Well Diameter Sealing Material Itop 501 I f f ' Depth ',Filler Material {Below 501 ,TYPE OF SEPTIC WORK: NEW INSTALLATION❑, REPAIR/ADDITION C1 DESTRUCTION ❑ (No septic system permitted if public sewer is \ f P _.- t available within 200 feet.) I Installation will serve: Residence.—-Commercial—, Other Number of living units: Number of bedrooms i 11 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal A aDistance to nearest: Well ° Foundation Property Line LEACHING LINE ❑1_No. & Length of lines r Total length/size FILTER BED .._,t ,•❑ Distance to nearest: Well ,Jf Foundation Property Line SEEPAGE PITS ❑ Dept'l Size' ' Numbere SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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. I 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 person's subject to workman's compensa- tion laws of Calif nia." The applicant u I for all q j4d inspectio . Complete drawing on reverse side. f r Signed lb'itle: Date: FOR DE RTMENT USE ONLY f Application Accepted by Date Area 9:�t / Pit or Grout Inspection by Date Final Inspection by Z I Date 7 �� Additional Comments: _ ❑ Stk 466-USI ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4: Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEk INFO AMOUNT DUE AMOUNT REMITTED CASH 'RECEIVED BY p DATE�r�- PERMIT"NO. + EH 13-24IREV.10!83} 113 EH 14-26