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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE:. } TON AVE., STOCKTON, CA - { Telephone (209) 466.6781 Ii @@r� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Py � ff L S Y r, l.�`f (Co�mJ Mete i T ' icat ) ~ Fn�bh rf ug Loral>A �It►S'D� r fb ��[, Application is hereby a o he Sa Jaa w c e istr P r a pe'rmi{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 wall/pump and the Rules and Regulations of the San Joaquin Local Health District. A�� I ' °�O #' b.•� Job Address City Lot Size k r f Owner's Nama k ] Address I �J Phone Contractor's Name License No. F / 3 rte# Phone 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 } I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - I �1 i�INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS per ❑ industrial El Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing i ❑ ,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ -Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dona 0 Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50'1 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is 1 I Installation will serve: Residence_ Commercial availle withln 200 feet.) _ Other �7`�trwy^ I Number of living units: Number of be rooms S, l Character of soil to a depth of 3 feet: Water table depth SE 'IT TANK ❑ Type/Mfg Capacit"y�� No. Compartments l PKG. TREATMENT PLT, ❑ / Method of Disppsal Distance to nearest: Well/1M Foundation _ Property Line LEACHING LINEfd No. & Length of lines !Total length/size FIL ER BED ❑ Distance to nearest: Well Foundation Property Line_JZ D ` I F r FjSEEPAGE PITS ❑ Depth Size Number 3Y SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ it 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 ll 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 em to tion laws of California." p Y persons subject to workman's compensa- 4 The applicant ust f all Min inspections C plate drawing on verse side. �} Signed Title: •- Data: r FOR PARTMENT USE ONLY _' Application Accepted by Data U r�a J� B 4 /rea 1 Pit of Grout Inspection by Date Final Inspection by 'r`� Date 1 Additional Comments: , e- LAG -C i ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ., Il FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH 6w- (REV 13-24 14•ffi 101831 ` /` i F 1 it