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k t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL' HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED vt+ +„ .. (Complete in Triplicate) k 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.Ryles and Regulations of the Sart Joaquin ` Local Health District. Job Address 7 �(1• y/-P� �� /9 _ City'S7Fnc Ya r, Lot Size g _ PM 1 d -�dl / �7 _2e. s " Owner's Name , .s5 rPS a r Address (r[�•~ /t,� Phone Contractor Address - License No. Phone i TYPE OF WELL/PUMP: 'NEW WELL ❑' WELL-REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 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 I❑ Tracy Type of Casing Specifications ❑ Public : " -0 Other .Y ❑ Delta Depth of Grout Seal Type of Grout t ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done {Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') V TYPE OF SEPTIC WORK:, NEW INSTALLATION 17 REPAIR/ADDITION K DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence✓ Commercial_ Other i Number of living units: v '! <Number of bedrooms 2- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal E Distance to nearest: Well Foundation Property Line LEACHING LINE 1; ' No. & Length of lines Z ��' Z Total length/size FILTER BED ` ❑ Distance to nearest: Well 6CiLr--C Foundation 2n Property Line s t SEEPAGE PITS ❑ Depth a Size Number � q SUMPS ! ❑ 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 rules and regulations of the San Joaquin Local Health District`a 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 workmaWS-'componsation-laws of California."Contractor's hiring or sub-contracting 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." The applicant ust call for all required inspec ns. Complete drawing on reverse side. J( 'Signed ` Title: _ Date: + y t FOR DEPARTMENT USE ONLY a F t Application Accepted by Date 'O�` Area 4 Pit or Grout Inspection by ' Date 4 final Inspection by5�,r _ _ Date a r Aoditional Comments: Stk 466-6781 ❑ Lodi 369-3621 i If-Manteca 823-7104 - 1 ❑ Tracy 835-M 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O:Box 2009, Stk., CA 95201 FEE f f f INFO AMOUNT DUE AMOUNT REMITTED # RECEIVED B "YDATE PERMIT"NO. + EH 13-24(REV:4/s51 EH 14-25