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c APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT EXPIRES E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 7 YEAR FROM DATE ISSUED k (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 describedri�. s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Ffegulatiuns of the San Joaquin Local Health District. t f`rl.tgfc�,f{ C Job AddressCity Lot Size PM L Owner's Name Address E Phone Contractor L Address? T10 License Np '? Phpne TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ ' f, SYSTEM REPAIR)9 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 1P ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0< "omestic/Private Cl Gravel Pack` ❑ Tracy Type of Casing Specifications f"1 Public ❑ Other r 17 Delta Depth of Grout Seal Type of Grout_ _ I I Irrigation —.Approx. Deprth /`I Eastern /S/y�dace Seal Installed by _ Repair Work Done X Type of Pump ,..7-� H.P. ./K State Work Dona Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is �. available within 200 feet.) Installation will serve: Residence_}Commercial_ Other _ Number of living units: _ Number of bedrooms i Character of soil to a depth of 3 feet: ' I � �" � Water table depth SEPTIC TANK ❑ Type/Mfg ., CapacityNo. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance td nearest: Well Foundation Property Lirg'- LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to,nearest: 'r well ly Foundation Property Line SEEPAGE PITS I I Depth Size Number ~ SUMPS - ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this applicatioKiind that the work will be done in accordadce with.San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local'Health district. .t Home owner or licensed agent's signature codifies 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 becdine subject to workman's•compensation taws of California."Ebntractor's hiring or sub-cantracting signature certifies the following:,'1 certify that in'Iheme4ormance of the work for which_this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California."The apOmust II for all required i ction om a drawing on re✓B�se side. Sign--, ,— Title, / P _ Date: %DEPARTMENT USE ONLYFSI Application n Accepted by ia" Area Pit or Grout Inspection by Date Final Inspection by 7 ,J-3T"1 Date ' v Additional Comments: ❑ Stk 466-8781 ❑ Lodi 369-362T ❑ 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 CK If fRECEIVED BY DATE PERMI7'NO. INFO AMOUNT DUE 1 AMOUNT REMITTED CASH (� a.EHI a.74 IIIEV 1/x51 3S,V0 H 14 r 4 v7d� E79 C