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I I 1 ' APPLICATION FOR PERMIT tt SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA ; Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED FILE � (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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San:-JoaquinLocal Health District. I Job Address ��uti�� s` L��`"�� f?t_ City � Lot Size_ 50 PM h `� ra o.i Phone — f P6 P Owner's Name �� J f 55 -� r Address �� QS �b Contractor Address "I!D License No. Phone 9"t0 g It I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE.TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y+ b Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing ;.. ..Specifications.'. 1-i Public F_-I Other Fl Delta Depth of Grout Seal Type of Grout — I i Irrigation —Approx. Depth . I I Eastern Surface Seal Installed by Repair Work Done ❑ `Type:of Pump H.P. State-Work Done • I Well Destruction. ❑ Well Diameter Sealing Material (top 501 Y Depth Filler Material (Below 501' TYPE OF SEPTIC WORK: NEW INSTAL TION l l REPAIR/ADDITION DESTRUCTION l I (Na septic system permitted if public sewer is r available within 200..feet.) Installation will serve: Residence_ `Commercial_ Other I ^ i Number of living units: _-I-__ Number ofbedrooms a+t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MtgeCapacity a No. Compartments a PKG.+TREATMENT PLT. ❑ . - r I Method of Disposal Distance to nearest: Well 1115r Foundation Property Line 30 f i LEACHING.LINE L-No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: ' Well /::t Foundation 'O r Property Line 3a 1 I � i SEEPAGE PITS I i Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Linb y DISPOSAL;PONDS El 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-'h rules and regulations of theSan Joaquin Local Health District. f 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's certifies 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. I Signed X Title: Date: t I FOR'DEPARTMENT USE ONLY ti Application Accepted by /- ] CA W Date '` ^ Area 4 Pit or Grout Inspection byDate N Final Inspection by Date AdditionalComments,�� -, ctca�..al[e-. .�-� _ r 2r OCG 5I Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 635-6385 pplicant--Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 - FEEtr INFO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. ♦.EH 13-24 4FEV,1/"51 V ' EH 14-26 { 7 4