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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZELTON AVE., STOCKTON, CA ¢, Telephone (209) 466-6781 P 4.b.- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) 4 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 welUpump and the Rules and Regulations of the San Joaquin r Local Health District, Joh Address ±t�len-G4� �iJ City 4 Ce7 Lot Size [ � PM Owner's Name JO-ILA �Z Address Phone Contractor (tCf_ Address_,e0 b 1 'License No. Phone �u S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION L1 x '` ; "" SYSTEM REPAIR L1 OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK F� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ~� AGRICULTURE WELL OTHER WEE L t t` ' t PITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑ Open'Bottom ❑ Mariteca Dia: of,Well Excavation' Dia. of Well Casing ❑ Domestic/Private 1 ❑ Gravel Pack �`. ❑ Tracy Type of Casing Specifications I'l Public ~� t f l Other ' F1 Delta .t Depth of Grout Seal Type of Grout I Irrigation —.-Approx. Depth. I ] Eastern Surface.Seal lnsialled by Repair Work Done'�A❑'f Type of Pump H.P. I State Work Done_ Well Destruction ❑ Well Diameter Sealing Material�(top 50'I ` Depth Filter Material f Balow 50T. f r TYPE OF SEPTIC WORK: NEW INSTALLATION I] _ REPAIR/ADDITION �DESTRUCTION I ] INo septic system permitted if public sewer is ' available within 200 reel.) Installation will serve: Residence"1 Commercial_ Other i F Number of living units: Number of bedrooms Character of"soiLto a depth`of 3 feet: ; n // Water table depth i SEPTIC TANK w �/Type%Mtg,f- pgy_ . `Dnc( pacity � a No. Gompariments PKG. TREATMENT PLT. ❑ u ( l x Method of Disposal Distance t nearest: Well jot)_ Foundation_ [- Property Line 160 LEACHING L14 IK No. & Length of Eines r" Total length/size FILTER 1BED # ❑ Distance toynearest: Well f Foundation 7_ Property Line { SEEPAGE PITS I I Depth Size"y Number + E SUMPS t L� Distance to neatest: Well Foundation Property Line E DISPOSAL PONDS ❑ 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. R 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." Contractors 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 CalifoF nia." i . I The applicant must call for all rqpuired inspections. Complete drawing on reverse side. * j t - t ss- Signed X Title: V1- Date: FOR DEPARTMENT USE ONLY 'rf1Il-`1- , 3 Application Accepted by Date AreaAA ` Pit or Grout Inspection 6y Date Final Inspection by 1 1 ,. Date Additional Comments: t c ❑ Stk 466.6781 ❑ Lodi 369-36211, ❑ 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 a r , i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24{REV.1 i A 55 EH 14-26