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y4 0 APPLICATION FOR PERMIT/ SAN JOAQUIN LOCAL HEALTH-DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 8 q q I T 1t, �► City Lot Size f �2 PIVI 3y Owner's Name V All �IV r 1 tY / _ Address L Phone Contractor T4T2tf,A Address Licen ✓ / Phone 73Y'/ TYPE OF WELL/PUMP: NEW WELL ❑ PL-ACEII+IENV7 STRUCTION ❑ PUMP INSTALLATION ❑ -- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAk FLD. PROP, LINE FOUNDATION ~AGR ICULTURE,_WELL-- -_OTHER WELL K� PITSISUMPS___2�1. INTENDED USE TYPE OF WELL LIPROB'LEM AREA CONSTRUCTION SPECIFICATIONS- O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy=; Type of Casing 2 f } Specifications FI Public nOther L]"Delta 5 Depth of Grettt-Sea! r ' Type of Grout I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by i Repair Work Done O Type of Pump '7( H.P, State Work Done_ r i Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is r .1 available within 200 feet.I s Installation will serve: Residence� Commercial_ Other y Number of living units: Number of bedrooms 9 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑- 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑l a Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ` Q No. & Length of lines _Total length/size! FILTER BED ❑ Distance to nearest: Well Foundation Property Line �y { SEEPAGE PITS I 1 Depth Size + Number 1 , SUMPS Distance to nearest: Well I 4D Foundation Property Lin?5_ DISPOSAL'PONDS ❑ I hereby certify that I have prepared this application and that_theavgrk_will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature-mortifies-the following: "I certify that in'the performance of the work for iwhich 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�o certifies the following: " certify hat in the performance of the work for which this ormit is issued,I shall employ persons subject to workman's compensa tP_ tion laws of Califor a.' ! {_ 1 The applicant m t c I for all quired ' pectians a drawing on reverse side. Signed X Title: Date: i I '%� FOR DEPARTMENT 115E-ONLY I , Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 t. L7 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 AMOUNT REMITTED CK 0 CASH... RECEIVED BY DATE PERMIT'NO .� EH13-24(REV.r/n5)FH 14-28 ....' A