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e R : APPLICATION FOR PERMIT �.` SAN JOAQUIN LOCAL HEALTH DISTRICT t •'." '` " ,. 1601 E. HAZEL T ON AVE., STOCKTON, CA . , k Telephone (209) 466-6781 ,�� w '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 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.� �f caau 1 CitytomLot Size , �f PM Job Address tr ' Owner's NameJam ess Phone We'll . j /lh C mP° �f �^ hone g f� / O'er r J P lire License No.sJ ____P Contractor��AbilJol./C Address O TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.Ak&PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _per& INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N rr Ll Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications 1 Public n Other C) Delta Depth of Grout Seal eiY Type of Grout r I I Irrigation at"4prox. Depth l I Eastern Surface Seal Installed by - Repair Work.Done ❑ Type of Pump H.P. State Work Done_ 1 Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is/, available within 200 feet.l �. sInstallation will serve: Residence Commercial Other T _ 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. ❑ '. Method of Disposal ± f Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size (� FILTER BED ❑ Distance to nearest: Well Foundation Property Line e SEEPAGE PITS I I Depth Size i. — Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 4 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 California." The applicant must call for all require ins ctions Complet drawing om-reverse side: - Signed Title, CA Date: �4 -Y7 i; FOR DEPARTMENT USE ONLY Application Accepted by I Date 4-7 Area Pit or Grout Inspection by Date Final inspection by Date InAdditional 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 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. H INFO CASH P;r a EH 13-24(REV,t 51 / 0-7- 00 10?2- 110 57--'2-2.07 ��° EH 14-26