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s 1.a 4 APPLICATION FOR PERMIT SAN JOAQUI.N 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 Sari 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. 1962 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address —. �jw /�TG '/C�` Gid Lot Size '` Ply --Owner's Name < r Address I/ �� Phone �� 1 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C1l 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 Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation y Type:of Grout– �qpprox. Depth ❑ Eastern Surface_SeaE dnstalled� Repair i Work Done ❑ Type of Pump - .P, State Work Done Well_Destruction ❑'!Well Diameters Sealing Material (top,50'), p r� Depth f Filler Material (Below 501 1" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ *REPAIR/ADDITION 17 DESTRUCTION C] (No septic system permitted if public sewer is ` available within 200 feet.) ty Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedroom`s. Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ T € - Ype/Mfg Capacity- No. Compartments PKG. TREATMENT PLT. ❑ oral Method of Disposal x p Distance to nearest: Well Foundation-_s Property Line --_ > f z LEACHING LINE ❑ No. & Length of linesTotal length/size FILTER BED ❑ Distance to nearest: Well Foundation ` Property Line 1 ll SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to'nearest: Well Foundation Property Line" DISPOSAL PONDS ❑ I 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 tFie-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.Cal'rfornia.'-' Goritractor`s hiring or sub-contracting signature certifies the foliowing: "i certify that in the performance of the work-for-which this lsdrh5i is issued, I shall employ persons subject to workman's compensa- tion laws of California." �_ -- -7, _f � `** �— -Thii applicant must cal for all required ins ions. Complete,drawing on reverse side. "Signed ��,..� Title: Date: 03 l y FOR PARTMENT USE ONLY r Application Accepted byDate �� Area Q Pit or Grout inspection by Date Final inspection by.q�i..ti.w Additional Comments: ❑ Stk 466-Ml ❑ 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 t' FEE INFO AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE' PERMIT`NO. + EH13-24(REV"1/s 5) 2EH 14 � Jr' ,C, 1.5 1�