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N APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,:STOCKTON, CA A Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,, �, ,..:(Complete in Triplicate),, „.1 bt' rjji V s 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. Job Address Al. y City Lot Size PM Owner's Name Address T M Phone "3 A WATER- Contractor i c e n s e No. IZ7 Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION LO I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:SEPTIC TANK 'SEWER LINES`_.- DISPOSAL FLD.. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS :INTENDED USE� TYPE-OF WELL ` P_ROBEEM AREA "CONSTflUC-TION-SPECIFICATIONS' t;. ❑ Industrial ❑ Open Bottom - ❑ Manieca Dia. of Well Excavation Dia. of Well Casing WDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Ll Public 71 Other 71 Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth LJ Eastern Surface Seal Installed by i Repair Work Done 0 Type,of Pump 5� ' H.P.. f State Work Done Well Destruction ❑ Well iameter Sealing Material (top 50') ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:` NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is _ 6 available within 200 feet.) i Installation will serve: Residence_ Commercial I Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i •rr Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D � Method of Disposal Distance to nearest:_ Wel1- - Foundatiohr-:'{ Property Line LEACHING LINE ❑ No. & Length of IinesL i 'y' Total length/size FILTER BED ❑ Distance to nearest: Well --- L•—^Foufilation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _ z. M 1 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. k 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 rnUsLcall fo all re uired inspections. Complete drawing on reverse ' e. Signed X Title: Da ts: r DEPARTMEN USE ONLY Application Accepted by Date_ a Pit or Grout Inspection by I Daie Final Inspection by Date Additional Comments: Y ❑ Stk 466-6781 ❑ Lodi 369-3621.fi1 Manteca...,.823=7104---t----0 Tracy---835-6385 1� p icant Return-allcopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA I g i ll FEE AMOUNT DUE' AMOUNT REMITTED CK RECEIVED�B� _ DATE PERMIT'NO. INFO CASH /f + EH 13-24(REV.i/n 5) • �( 1p �'� "��0 ' EH 1428