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�9 APPLICATION FOR PERMIT i" SAN JOAQUIN LOCAL HEALTH DISTRICT ' I� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �? PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he"eby 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. 548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 'J e 0. City �� Lot Size PM Job Address �g/G� P ��E'�4 Address r T�l"r'r /�' Phone Owner's Nam Contractor Address C/' � _License No TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION »,-. SYSTEM REPAIR C1 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 El Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing X16ornestic/ ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications 11 Public C1 Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I Eastern Surface Seal Installed by - 11 Repair Work Dane ❑ Type of Pump H.P. I State;Work DoneGf[7 I 1 ' ' Well Destruction ❑ Well Diameter Sealing Material [top 501 ii Depth. Filler Material l8elow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION l 1, REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is " available within 200 feet.] Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK' ❑ Type/Mfg Cap2city%_- 1 No. Compartments PKG. TREAT MENT,rPLT. L7y Method of Disposal y Distance to nearest:-V Well= —�Foundatian Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size -FILTER BED ❑ Distance to-nearest: VWell Foundation :Property Line I SEEPAGE PITS l I Depth Size Numbers+ SUMPS ;1 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j 4 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. 7.. 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."Contractors hiring or,.sub-contracting signature certifies the follo ing:�"I certify that in t performance.of the work for which this permit is,issued,I shall employ persons subject to workman's compensa- tion laws of of rnia.' L + , r t • s The applic t'm st*a r all q ire i spections. Complete drawing o rev rse id Signed X3- Title: ► Date: IR DEPARTMENT USE ONLY II - �� Are Application Accepted by Date a 04 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 20D9, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO h^ C ..EH 13-24(REV,I/n 51 d� ✓ �.o$ 13 �.7 EH 14-26