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F as APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.--1 ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T (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 i 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. „ s.• Job Address 200 S , I Vl A City [� I `lot Size PM rr�s �a�-lo�lg '�Owner's Nae Address Phone m Contractor Address ` License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 1NSTALLATIO SYSTEM REPAIR'❑"` OTf -❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s 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 t ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation _Approx. Depth ❑ Eastern - Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 rrREQF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is available within 200 feet.) Installationwill s _ Residence Commercial_ Other Number of living units: umber of bedrooms f Character of soil to a depth of 3 feet: Water table depth t i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. L1 :c Method of Disposal Y �"H Distance to nearest: Well anon Property Line LEACHING LINE ❑ No. & Length of lines ; 0�ze_ FILTER BED ❑ Distanceto nearest: Well Foundation SEEPAGE PITS ❑ ,y Depth Size Number l i SUMPS ❑ °:Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ r.f # 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 workmari'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 4this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drayving on reverse.side. d Signed X "w -�---�- Title: Date: FOR DEP TMENT USE ONLY a Application Accepted by " � 1 Date ^3 Area Pit or Grout Inspection by date` Final Inspection by Date l Additional Comments: � Y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca`823- f04 ❑ Tracy $35-6385 I ' 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. y INFO 71H4EH 13-24 MiE .rias} �]YEH 14-26 `! t it