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t n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA f � Telephone (209) 466-6781 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 r�, ., .,, Y . . ,� ~• : s:. .,:,.(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 cornpllance 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. r .. •. . : r 00, [ City r Lot Size PM Job Address OwnerPhone 's Name , � '�-- "' Address + " 4 Phone f V - ;� Contractor's Name License No. j 09 jr TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T ❑\, DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM FC REPAIR ❑ � ;OTHER. 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. T PROP. LINE FOUNDATION !' AGRICULTURE WELL } OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom j ❑ Manteca Dia. of Well Excavation Dia. ;Well Casing ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casin Specifications ❑ Public C1 Other ❑ Delta Depth of Grouj.Seal_ Type o_f Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i '�s ' *. I State Work Done Repair Work Done ❑ Type of Pump H•'P4 Well Destruction ❑ Well Diameter Sealing'Material Itop 501} Depth t Filler Material IBelow 50':l TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) # Installation will serve: Residence_,iff-Commercial— Other Number of living units: Number of bed ms j i ' - Water table depth r Character of soil to a depth of 3 feet: Cl) SEPTIC TANK 17Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal " Distance to nearest:' � Well Foundation � Property Line LEACHING LINE 2�"No. $ Length of lines _h _ Total length/size FILTER BED ❑ Distance-to nearest: Well 0 Foundation ' 'Property Line SEEPAGE PITS ,Js Depth Size Number SUMPS ❑ Distance to nearest: Well�.�"'"'Foundation Property Line DISPOSAL PONDS ❑ v ` i .y A l I hereby certify that I have prepared this application and that the wory k1I'.b6done,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."Contractors 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." 11 S The applicant ust 11 for all requir spections. Com eta drawing on rete a side. Af Signed Title: Date: / FOR AR ENT USE ONLY r Application Accepted by �' Date `f 7 rea Pit or Grout Inspection by f Date '< < final Inspecti/ron by A/Additional Comments: r ❑ Stk 466-6781,•-r- - ❑ Lodi 36.9-3621 ❑ 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 FEE` AMOUNT DUE` AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. =INFO + EH 13-24 IREV.101931 0. �� EH 1426 I.c