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"v APPLICATION FOR PERMIT ��.�,� i t SAN JOAQUIN LOCAL HEALTH DISTRICrD 'N ' *-, • _ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISS (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 matte 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 412 r J City Lot Size / PM Owner's Name ddress t' Phone Ir Contractor�J�� Addres's License No Phone r / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ef DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 YV ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i F1 Public F Other la Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth t I Eastern Surface Seal Installed by _ 1� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF,SEPTIC WORK: •NEW INSTALLATION 1#1 REPAIR/ADDITION I I DESTRUCTION 1 ) INo septic system permitted'if public sewer is Y/ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: J— Numberof bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 0 Method of Disposal Distance to nearest: Well 149 0 1� Foundation lL_._._........_ Property Line I LEACHING LINE 11K No. & Length of lines �~ ToV1 length/size ' FILTER BED ❑ Distance to,Tiearest: 1 Well Foundation C5 O Property Line _ SE=EPAGE PITS l I Depth Size Number JJ� SUMPS ❑ 'Distance to nearest: Well oundation Property Line 1 DISPOSAL PONDS ❑ hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ti 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 workman's compensa- tion laws of California." The applicant u t c r all requir d'in pections. Co late drawing a gorse side, .ry � Signed X Title: Date: a FOR DEPARTMENT USE ONLY Application Accepted by Date 67 7 !f / Area e � Pit or Grout Inspection by r Y Y Datey Final Inspection by a�F o XML WDate=g Additional Comments: &J O 0 E) Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-71 Tracy 83$-M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n, ,l FEE I INFO A—M7OUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO., I + EH 13-21(ECFV.t i k s1 //1.,- 7 OQ' 0�' EH 11-2e !! c� QC!