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T ~' APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA U-f Telephone 1209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andior install the work herein described."This application is made in compliance'with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wellIpump and the Rules and Regulations of the San Joaquin Local Health District. C �� `,,� Job Address �✓ Cit y�_LYC,Clpb't Size PM Owner's Name ' /� � Address Phone r C Address� 0 W O License Nom 138 Phone �3 C Contractor 1 . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L3 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES - DISPOSAL FLD. PROP. LINE" 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 ., ("I Public n Other 11 Delta Depth of Grout Seal Type of Grout _ I Irrigation —.Approx. Depth I I Eastern SSurface Seal Installed by _ Repair Work Done L3 Type of Pump H'.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 541 Depth Filter Material (Below 54'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION N1,4FESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: . Resi encs L"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 C,nkJC Capacity./ No. Compartments PKG. TREATMENT PLT.© P"� .L C 0 1a,Ct- Method of Disposal VJ Distance to nearest: Well Foundation Property,Line LEACHING LINE L�-�R1o. & Length of iines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 e rules and regulations of the San'Joaquin Local Health Dikttict. 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 cert''es the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion a f California." The applican t call all r�uirod '�Octi ns. Com a drawing Mvodrse , e. Signed Title; Date: �g FOR DEPARTMENT USE ONLY Application Accepted by Date C'�-L ' Pit or Grout Inspection by ii Date Final Inspection by Date Additional Comments: I 0 Stk 466-6781 ❑ Lodi 369-3621 EI 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 13Y DATE PERMIT NO. INFO CASH +.EHt3•24 iRIEV.t/x 51 EH 14.25 /