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J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA } Telephone 12091,466-6781. . i : . PERMIT EXPIRES TYEAR 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 L 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. I - Job Address G _'City � -��_ Lot Size PM OWn �i �l � � Address .� l� Phone;� 3� Q er's'Name _�_ Contractor ��= 1i Address License No, Phone_ ..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 FQUND, TMON: AGRICULTURE WELL ' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing LJ Domestic/Private ❑ Gravel Pack ❑:Tracy Type of Casing Specifications Fl Public ❑ Other171Delta Depth of Grout Seal Type of Grout _ QS_ 1 I Irrigation _Appropx. Depth l I Eastern Surface Sual Installed by _ t Repair Work Done ❑ Type of Pump = H,P. ••--- --- - State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i:1 REPAIR/ADDITION 1.1 DESTRUCTION VNNo septic system permitted if public sewer is J a ailable within 200 feet.) installation will serve: Residence_t 'Commercial_ Other y Number of living units: Number of bedrooms f 9 a. Character of soil to a depth of 3 feet: - Water table,depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance+to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Eaws, 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 becd7he subject'to workman's compensation laws of California." Contractors hiring or subcontracting signature certifies the following: "I certify that in the pert i;nance:of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal' ,ia." The appli t mus call for all require spections. Complete drawing on reverseaide. S• Ww`" • , Sign Title: [{� y Date: Y FOR DEPARTMENT USE ONLY Application Accepted by _ Dateu Area Pit or Grout Inspection by Date :Final Inspection by-5___(2&d. (ACL Date Additional Comments: __ / 6 t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 ` INFO AMOUNT DUE 1 AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. EH 13-24 1i ()C) V/� Y + TREY.tin51 ��'� � .. S EH 14-28