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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �j U 1601 E. HAZEL T ON AVE., STOCKTON, CA vc Telephone {209} 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I Ni", 44 �ViUE Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descripivA p'lrcation 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. j _ Job AddressG-.«' r -- City Lot Size PM l� / Owner's Name r Address P� �X7 Ca-- Phone Contractor r Address - l`1erise No. Qom ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR El 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 Industrial El Open Bottom L1 Manteca Dia- of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FT Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approx. Depth - I I Eastern" Surface Seal Installed by _ Repair Work Done LlType of Pump H.P. State Work Done Well Destruction .. ❑ Well Diameter. Sealing Material (top 501 Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic stem permitted if p y p public sewer is � available within 200 feet.) IE Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line. LEACHING LINE ❑ No. & Length_of lines Total length/size FILTER BED _ ❑ Distance to,nearest: Well Foundation Property Line { SEEPAGE PITS I I Depth Size Number SUMPS j ❑ Distance to;ne.r`est: .: 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 ' rules and regulations of.the San Joaquin Local Health Di§trict. 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 i employ any person in such manner as to become subject to workman's compensation laws of California.".Contractor's hiring or subcontracting signature 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." a The applicant must II for all rE ' pections. Complete drawingo verse side. 3 Signed �l Title. Z14- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �` Area Pit or Grout Inspection by ## ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ 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 i FEE INFO AMOUNT DUE y AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. 0 +.EH 13-24 IREV.I It 5) EH 1428