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F APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone-(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 i 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 �v Cith-c-INC4 rdo Lot Size PM — j 4 Owner's Name +l Address 7' hon {� Contractor ? Address V License No._. 0• Phon,7_ '� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS 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 y F1 Public 17 Other 171 Delta Depth of Grout Seal Type of Grout _S _l , I I Irrigation —_Appfox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump k H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material I Below 501 — O TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is o I availahle within 200 feet.) f 1� Installation will serve: Residence Commercial— Other 1/t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:'; Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal {� Distance to.nearest: Well Foundation Property Line ! PP 1 LEACHING LINE ❑ No. & Length of lines Total length/size r- r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS- ham- I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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. - I 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 m all f '�all req ed inspections. Complete drawing an reverse side Signed X ��AA�' Title: " Date: 1 FO DEPARTMENT USE ONLY Application Accepted by QQC - fid Date Area r p Pit or Grout inspection by Date Final Inspection by S` — Dated(/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. INFO +.IsH13-24 iREV.�/e s) EH 14-26