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E APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA p Telephone (209) 466-6781 a �� c PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 (Complete in Triplicate) I 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. I �� ,,/ Job Address / � f Imo!! �{ City ,Lot Size PM f { Owner's Namepr _ Address a t'ii PF1Vone !! 1 IL Contractodress_i_�]__o�:)C t Z - LicenseNo.! Phone DGS w�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE i s' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Inldystria1 ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` ❑ Public ❑ Other C7 Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ stern/ /J Surface Seal Installed by L; Repair Work Done GR�Type of Pump .5 5-4 ,Jd�C_ _L _ ___ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is :I available within 200 feet.) ,! Installation will serve: Residence_ Commercial____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments p PKG. TREATMENT PLT. ❑ Method of Disposal tib Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 li nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not nner as to become subject to workma 's compensation laws of California."Contractor's hiring or sub-contracting signature employ any p on in sucT $ certifies the Ilowing: "I ce f that in the pe rmance wo for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws California." The app cant r all re r complete rawing onztt� Signed Title: Date: f/ ^// Al i FOR DEPARTMENT USE ONLY i �.�r�iJ __ Area i I Application Accepted by Date� " c� p Pit or Grout lnspectio y Date Final Inspection by Date Additional Comments: .❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 a t INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. + EH 13-24 iREV.i Eli 14-28 • '�F7 ,�