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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �¢ l Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l � � . {Complete in Triplicate} APP, 1939 J 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 Rule`s aqd Regulatidns of the.San Joaquin Local Health District. Jab Address �+!a n Y City Ji[ Lot Size PM Owner's Name d ' Address f _ Phone ff c I` Contractor L�e -I Address _ - L License No. PhonS y 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,Industrial ❑ Open Bottom ❑ Manteca �'Dia,-of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I 1 Eastern Surface Seal Installed by s Repair Work pone Type of Pump rhe. H.P, (1h=� -- State Work Done [ Well Destruction ❑ Well Diameter Sealing Material (top 50') y Depth Filler Material (Below 50') TYPE_OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION'la Wo septic system,permitted it public sewer is I available within 200 feet.) d Installation will serve: Residence_i Commercial— Other S Number of living units: Number of bedrooms `. - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. n ' 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 l I Depth I Size Number SUMPS Ll 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 y rules and regulations of the San Joaquin ILocal 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 California." The applicant t a I for all req iced in fpections. Complete drawing on reverse side. Signed X TRW Date: 3 — 30 C / F R DE ARTMENT USE ONLY �J� Application Accepted by --e f I Date t7Q Area Pit or Grout Inspection by Date Final Inspection by Date 9 �fy Additional Comments: F v' ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y OATS PERMIT'NO. INFO CASH +.EH 13-24IREV.11851 � EH t4-2a