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APPLICATION FOR PERMITS SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZELTON AVE., STOCKTON, CA N� Telephone (209) 466-6781 ND PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (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 we11/pump and the Rules and Regulations of the San Joaquin Local Health District. i) Lot Size PM Job Address �,Q 1��L�/r ; Address `� G Phone k Owner's Name t I`/ I T ` ICfiNIC /N i�LAP / ' 4 �[�d� PhonContract Address (cense No.TYPE OF WELL/PUMP: NEW WELL ❑ EPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑.Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public Cl Other l Delta Depth of Grout*Seal-,", Type of Grout -- I Irrigation ..Approx. Depth I I Easterner Surface Seal lnstalled.by_ -- Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material itop 501 }Z] Depth Filler Material Melow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION (Noseptic system m rmiitted if public sewer is avak Installation will serve: Residence— Commercial_ Others Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT" ❑ ; Method of Disposal 11 Distance to nearest: Well Foundation � ' #'Property Line LEACHING LINE ❑ !I No. & Length of lines J Total length/size FILTER BED ❑ I. Distance to nearest: Well Foundation Property Line ! I SEEPAGE PITS I I Depth Siz�� Number SUMPS Cl '. 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Heal h 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 su ject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performs ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif rnia." Ii I The applican mu t tail for ail requir i specti s. Complete drawing on r Signed X Title: Data: FOR DEPARTMENT USE ONLY Application Accepted by Date L Area Pit or Grout inspection by �l Date Final Inspection by r Date II I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r= Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE OUNT DUE AMOUNT REMITTEO CASH RECEIVED BY DATE PERMIT NO. INF �--�� /f! fl-,X� 7EH13-24 iREV.t i K 51 c7 dUV `*�V 1 � F ; - yv / EH 14-26 n I