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f 'APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1.601 E. HAZELTON'AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED (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 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. i r 7i ��, r Job Address v iQ3_ E-, -� L I`7i[ City Lot Size PM rI r Owner's Name iiLeJ Address 4vPhone Contractor's Name." 0,Q icense No: _ Phone TYPE OF WELL/PUMP: NEW WELL ❑' WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ -• SYSTEM REPAIR L!i� 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 1 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing la'bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications ❑ Public El Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation ---Approx. De h 0- Eastern Dep ,� ur ace Seal Installed by Repair Work Done" ❑ T p _' ___ Ci� t� l Type of Pum t --N 11 rP State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Materialf4Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is y available within 200 feet.] To `Installation will serve: Residence_ (Commercial Other Number of living units: Number of bedrooms { Character of soil to a depth of 3 feet: I i Water table depth SEPTIC TANK ❑ Type/Mfg .1 l Capacity { No. Compartments i PKG. TREATMENT PLT:❑ i Method of Disposal Distance to nearest: Well Foundation PrIpperty Line LEACHING LINE-',—,' °!�_�No.,.&Length of-lines ------- -- __-Total len ith/size FILTER BED Cl Distance to nearest: Well Foundation Ploperty Line SEEPAGE PITS ❑ Depth I Size Number SUMPS 11Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 i:he work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califor ia." The applicant ca for all reqre nspectionsl. Complete drawing on reverse side. Signed ri-✓ �!4itle: € Date: 0i Y FOR-DE PARTMIENT.USE ONLY,,.,,..- Application Accepted by Date Area Pit or Grout Inspection by Date�T Final Inspection byDate S-��/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621:1 ❑ 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 I FEE AMOUNT DUE AMOUNT REMITTED.-• CK RECEIVED BY DATE PERMIT"NO. INFO CASH + EH 13-24(REV.101931 ,A 5'- o O 7�` EH 1429