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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZE T ON AVE., STOCKTON, CA i Telephone {200) 466-6781 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 compfiance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and,xhe Ryles and Regulations of the San Joaquin Local Health District. F Job Address City - �C Lot Size 'i acu_ PM Owner's Name 4 J Address 9 1 Phone !r Contract r '.V. Address y tf), 4License No3.29t2 Phone 0— /( F ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER -❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F411!. FOUNDATION" AGRICULTURE WELL OTHERWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fr ❑ 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 F, Repair Work Done ❑ Type of Pump H_P_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r 1. Depth Tler Material (Below 501 ^� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR ' DDITION FDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) �. k Installation will serve: Residence Commercial Other d Number of living units: / Number Character s L� Character of'soil to a depth of 3 feet: - L� TC'J� _ - Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE IiND. & Length of Dines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation �C�r Property Line ' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanyes, 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"" Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California_" The applicol must call f a ,required inspections. Complete drawing on reverse C. -30 Signed y J Title:�� Date:. � '� I L. - FOR DEPARTMENT USE ONLY Application Accepted by � -e' t Date �� J Area Pit or Grout Inspection by Date Final Inspection by �p Date 4 Additional Cornments: r!/� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 8355-6385 } Applicant- Return all copies to: Environmental Health Pemrit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 FEE AMOUNT DUE AMOUNT REMITTED CKW RECEIVED BY DATE PERMIT''NO. F,13-24 IREvINFO CASH,1/a s) EN 1426