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Ir - f } ll APPLICATION'FOR PERMIT `=1i SAN JOAQUIN LOCAL HEALTH DISTRICT li 1601 E. HAZELTON AVE., STOCKTON, CA f-j 0 I��,�{ 0 �� Telephone (209) 466-6781 II PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUJI-q LOCAL ��- � y�A�.rH a�srRICr J� II (Complete in,Triplicate) Application is hereby made to the San Joaquin Local Health District fol:,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 Joaquin Local Health District. Job Address r City aQ kGL/ Lot Size PM Owner's Name Address qq one –� Contractor's Name License No. Q Phone TYPE OF WELL/PUMP: IiUNEW WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPIINSTALLATION ❑ SY T��JJ�REPAIIR ❑ OTHER ❑DISTANCE TO NEAREST: 5EPT1C TANK SEWER LINES��/ DISPOSAL FLD 21 PROP. IN - FOUNOATION-`"�'�""` ,.—� �'AGRICULTURrWELL OTHER WEyLL TS/BLIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ff Manteca Dia. of Well Excavation p �y,/� Dia, of Well Casing Domestic/Private ]+'[',ravel Pack ❑ Tracy Type of Casing Specifications l ❑ Public ❑ Other ❑ Delta Depth of Grout SealJ ---,I Type. rout ��JL ❑ Irrigation pprox. 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,50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Na septic system permitted if public sewer is u available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: 11 Number of bedrooms 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 ' Distance to nearest: Well Foundation Property Line IH LEACHING LINE ❑ No.& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ; Property Line � SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well __. Foundation Prope❑� --L–ine� , � ` "-DISPOSALPONDS 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. 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 certifies the following: "I certify tha i 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." I; The appli nt ust call for all requir inspections. C plate drawin on rev a side. Signed Title: (� Date: Z2 FOR DEP TME SE ONLY Application Accepted by DateArea " Pit or Grout Inspection by Date 'a Fnal Inspection by Data II ! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83&-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE .II _ INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. +111.14-26-EH 13-24`REV.10183]