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1►-r-� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE., STOCKTON, CA N03 � ti• Telephone (209) 466-6781 R _ / PERMIT EXPIRES 'f'YEAR FROM DATE ISSUED No ! (Complete in Triplicate) 'I'VIVI' 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 I Local Health District. C r I Job Address Q2267.1, �ciity. t Size PM + Owner's Name Address � � rf � .SIC Phone Contractor Cl'C Address License No. Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-❑ t DESTRUCTION ❑ gJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (n i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �11 ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing '' Specifications 5 Type of Grout ❑ public i.1 Other � F] Delta Depth of Grout Seal � YP ' I I Irrigation _ Approx(Depth l I Eastern Surface Seal Installed by 011 Repair Work Done- ❑ Type of Pump H.P,. State Work Done'+' 10 Well Destruction ❑ Well Diameter Sealing Material (top 501 ` t. Depth Filler Material (Below 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION l I- DESTRUCTIO174-(No septic system permitted if public sewer is s available within 200 feet.I Installation will serve: Residence, Commercial_ 'Other Number of living units: . Number of bedrooms Character of soil to a depth:of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ,Capacity - No.,Compartments Q I, PKG..TREATMENT PLT. ID Method-of Disposal - ! Distance to nearest: Well v Foundation Property Line �} LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS i '.,Ll Distance to nearest: Well Foundation Property Line l DISPOSAL PONDS ❑` r I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin county ordinances, state laws, and rules and regulations of the.San Joaquin Local-Health District. that in the performance of the work for which this permit is issued, f shall not Home owner or licensed agent's signature certifies the following: "1 certify 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 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 applican t call for all required ins coons. Co late drawing on reverse side. Signed X Title: Date: r ' C FOR EPARTMENT USE ONLY Application Accepted by n.;7.----1 �' Ara Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments:' r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Envircnmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 1 C � FEE AMOUNT DUE AMOUNT REMITTED t K RECEIVED BY DATE PERMIT NO. INFO ff11 C EH 43-24{REV.i/Hsl I'D -247 7 EH 1426 _4.