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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 A C, (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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$_62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District 3. '� > ► ,. r;4 :1' .,r,. :i Rf Yi I w (" II . Y}K.[ Lot Size {®� X c��--PM Job Address City Owner's Name Phone J61714 20' I` Contractorw4�1a� � A` ddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION K r'ti PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r.. DISTANCE TO NEAREST:;,SEPTIC TANK SEWER CINES` DISPOSAL.FLD. PROP. LINE 2 ` ;FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE !�TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -A�omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 0 Other ' ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ;�___4pprox.' 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 1 ,r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT�P (No septic system permitted if public sewer is it , available within 200 feet.) Installation will serve: Residence_ Commercial_ Other . Number of living units: ` Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ��!�?t° IC? Q Capacity _ No. Compartments I PKG. TREATMENT PLT. ❑ '[ Method of Disposal it Distance to nearest: Well Foundation Property Line i LEACHING LINE 11 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 0 Depth r Size Number SUMPS 0 Distance to nearest: Well Foundation- Property Line DISPOSAL PONDS 11 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. 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 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 m t call for,ail required inspections. Complete drawing on reverse side. -T �} ei I p Signed X # Title: , Date: a F PART ENT USE ONLY Application Accepted by -- - - -Date_ Area Pit or Grout Inspection bye Date t Final Inspection by &'/ Date i Additional Comments: ❑_Stk_.466-6781_.__,I7l Lodi- 369-3621-- 0-Manteca823-7104 .,-,' ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601E. Hazelton Ave..P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUEAMOUNT REMITTEDCK H RECEIVED BY DATE PERMIT"NO. INFO !� !, + EH 13-24(REV,I H 5 `/ �V gg-,00 t,,. ` �/ �P, J7— 1 EH 14-28