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w APPLICATIONiFOR PERMIT �5 ' + r.• ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , (Complete in:Triplicate) �4 -t ` - .. ,, ' . ° 4 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 Joaquin Local Health District. . Di ^ City .y� y Lot Size 1�'S X67 `PM Job Address 7ta� lw��.� S _ -_ " +, Phone Owner's Name Address ' Contractor Address .r �\ License No. Phone h' TYPE;OF' NEW WELL 71 WELL REPLACEMENT E1 DESTRUCTION ❑ a w NSTALLATION ❑ SYSTEM REPAIR ❑ 11 OTHER ❑ 1 t DISPOSAL"FLD:" 'PROP_CINE DISTANCE TO NEAREST: SEPTIC TA SEWER LINES x J ' K>4�FOUND +ATION' GRICULTURE WELL OTHER WELL PITS/SUMPS ' --INTENDED..bSF STYPE OF WELL PROBLEM AREA STRUCTIOIV SPECIFICATIONS *`. fl Industrial ❑ Open Bottom ❑ Manteca `Dia. of avation Dia. of Well Casing ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy "Type of Casing v Specifications 4. ❑ Public�, ❑ Other ""❑ Delta` ' - " Depth-of Grout Seal. Type of Grout ❑ Irrigation L___4pprox: Depth ❑ Eastern Surface Seal Installed by \ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction- ❑, Welf"Diar6eter, Sealing Material (top 50'1 3 Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sew-er is available within 200 feet,) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3'feeti; Water table depth ` c t' Capacity No. Compartments SEPTIC TANK [7Type/f+Af9 Ca P Y PKG. TREATMENT PLT. ❑ Method of Disposal i tx, Distance to nearest: Well Foundation Property Line ' j 1 ✓ -d' LEACHING LINE 11 No. & Length of lines Total length/size rr I FILTER BED ElDistance! to nearest:" Well.- "'Foundation Property L-irfe y SEEPAGE PITS ❑ Depth I Size Number 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 t rules and regulations of the San Joaquin Local Health District. . . i 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 i 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 compense- k tion laws of California.' E The applicant must calllor all r quired inspections. Complete drawing on reverse side. s . t { Title: A €. Date: 1 a Signed X FOR DEPART M NT USE ONLY �ry Area ' Application Accepted by r Date R Pit or Grout Inspection/b'y Date Final/Inspection cb�yy. ate r 1'Z Additional Comments.y �- r / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma 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 FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. INFO t + EH 13-24(REV.1iesl �7 �9 EH 10.29 r� _