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t M.ti. r w 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE., STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u1 1,� .. (Complete in Triplicate) Y ; .. Application is hereby made to the San Joaquin Local Wealth 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. 4 Job Address City.! "C' - DWLot Size a PM Owner's Name Address pt"Al Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ' ' DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 5 ' I. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —..Approx. Depth ❑ Eastern Surface Seal Installed:by �- t Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material !Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION NINo septic system permitted if public sewer is ' ' -available within 200 feet.] Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 FILTER BED ❑ Distance to nearest: Well Foundation pro perty`Line SEEPAGE PITS ❑ Depth T Size Number >f SUMPS ❑.: Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j p 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 r rules and regulations of the San Joaquin Local Health District. i - - 4 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,'l shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for pil req wired inspections. Complete drawing on reverse side. Signed X Title:; �AM?�4 C 70 � Date: S 1l5 7 FOR DEPARTMENT USE ONLY j Application Accepted by < ' Date - Area O t Pit or Grout Inspection Date Final Inspection by Date lac7yi�.� I Additional Comments: �'S 7/Jat ' ❑ Stk 466-6781 ❑ Lodi 369-3621,} ❑ Manteca 823-7104 ❑ Tracy 835-6385 F Applicant- Return all copies to: Environmental Health Permit/Services. 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 FEE f INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.' + EH t3-24{REV.iia 51 � �U p �C^� �i Y a r��r ^7 ��r � (0 I EH 14-28 V��y i