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F - -� 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 (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. 1862 for well/pump and the Ryles and Regulations"of the San Joaquin Local Health District. " Job Address City vGL Lot Size PM / 1I J Owner's Name Address 4 )V 6_' 0,41►1 Phone �G�- S I "IZu` Z Contractor " 3' ` Address K A>!vd A rn License No. Phone /J 27 g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a- In Dia. of Well Casing Z ` r VJ, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Ute° / Specifications f 1-1 Public 3 N 4 Other --❑ Delta - Depth of.-Grout-Seal— w �-e s Type of Grout �� C ❑ Irrigation 6.1P1�f_ --Approx. Depth 1D Eastern Surface Seal Installed by W Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .,. available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms w Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance Fto nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total-length/size FILTER BED ❑ Distarice'to nearest:' Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation rProperty Line DISPOSAL PONDS ❑ 3 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. 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." The applican st call for all required ins tions. C mplete drawing on reverse side. Signed - Title_ 16 - Date: 5 PA USE ONLY i Application Accepted by J Date r a Pit or Grout Inspe . a y ateFinal Inspection by Date-,,,,, t , Additional Comments: ❑ �� ❑ Stk 466-fi781 Lodi 369-3621 ❑ Manteca ❑-7104 racy 835-6385 B, 4� 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo 2009, Stk., CAFEE 95201 INFO AMOUNT DUE AMOUNT REMITTED CKRECEIVEDRE"C�E�ItVED BY DATE PERMIT"N0. + EH 13-24 1 REN-i/s 5) - 1430 1 q (u►/ � �,~�� SS' EH 14-26 ff V_Y i I