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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (20_9) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED ; (Complete in:Triplicate) f Application is hereby made to the Sah'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 P2 o o I�Le 1 `e City W Lot Size PM " _ � Owner's Name Td tS Address tel."r Phone ' Contractor Address o License No.��7DS Phone T ��Z ' TYPE OF WELL/PUMP: NEW WELL t VtiWELL,REPLACEMENT,❑ DESTRUCTION ❑ � — DISTANCE' INSTALLATION �-� 'SYSTEM REPAIR'❑ " OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK —,SEWER- - - - --��-�----- LINES DISPOS;4L FCD: -�----r -'pROP--LINE�'"""�- " "�' FOUNDATION AGRICULTURE WELL 07HER:WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r---� � ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %?Domestic/Private +'Gravel Pack ❑ Tracy Type of Casing rev,' Specifications . ❑ Public CI Other ❑ Delta Depth of Grout Seal �' Type of Grout,_ mint Q C3 Irrigation --Approx. Depth 17y Eastern Srrface Seal Installed.b T _ r . Repair Work Done ❑ Type of Pump �'yff H.P. I State Work Done Well Destruction ❑ Well-Diameter Sealing Material Itop'50'1 Depth Filler MaterialABelow 501 �'--7TYPE'OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic,system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial Other , Number of living units: Number of bedrooms E ' Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity . � 1No.`Compartments PKG. ]�- TREATMENT PLT. ❑ I I Method of Disposal Distance,to nearest: - Well Pro11 perty Line LEACHING LINE' ❑ No. & Length of lines Total length/size FILTER BED-_, a ❑ Distance'to nearest: Well � Foundation Praperty Lirtel 1 ! t V { SEEPAGE PITS ❑ Depth Size Number 1 f F SUMPS ❑ Distance to nearest: Well .-- Foundation= p�operty Line` DISPOSAL PONDS Cl 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 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." 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 workmen's compensa- tion laws of California." ; The applicant must call for all re uired inspections. Complete drawing on reverse side. t Signed X� ,J Title:" Date: 3 ' 'i ��OR�DEPART�MENT�USELY Application Accepted by Date-3-a--co�j Area Pit or Grout nspection hy" U Date Final Inspection by u °a �� Dat 3__ G! Additional Commen ` ❑ Stk 466-6781 ❑ Lodi 369 3621 anteca 823-7104 O Tracy 835-6385 i Applicant- Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT.DUE AMOUNT REMITTED tD gyp,- INFO CASH RECEIVED BY DATE PERMIT•NO. Iles l rv5- dem l + EH-13-24(REV.1/N 5) ^h f /� 9046 EH 1428 {/V r �� `�-' v ? h