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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCACHEALTH DISTRICT 1601 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 her describad.^This application is made H 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 t Local Health District: E Job Address � � � ;1� � C-- City , t _ �� Ir City r Lot Siz PM Owner's Name b c "'Address t Phone Contractor Address F' License No. TYPE OF WELL/PUMP: NEW WELL ❑ Phone WELL R_EPLgCEMENT-0 D_EST_ RUCTION ❑ + PUMP INSTALLATION ❑ # - SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK f- SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION =.k r AGRICULTURE WELL OTHER_WELL�� f INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS )PITS/SUMPS 1 J ❑ Industrial Open Bottom ❑ Man~ teca Dia.-of-Well Cas Excavation —Dia. of Well Casing .� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type- F ype of Casing i Specifications' _ Q Public [ ❑ Other g S # El ut` al Depth of Gror' [ Irrigation Approx.4Depth ❑ Eastern Type of Grout _LSurface Seal Installed bye C I Repair Work Done' ❑ Type of Pump'- H.P. Well Destruction # State Work Done:, 1 i ❑ Well Diameter Sealing Material (top 56 r I Depth �K Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTI0N1❑ (No septic system permitted if public sewer is J Installation wg available within 200 feet.) 71 serve: Residence� mmercial— Other Number of living',units: Number,of bedrooms Character of soil to a depth of 3 feet:. pry I 4 ! SEPTIC TANK � Water table depth ❑ Type/Mfg' � L� PKG. TREATMENT PLT. ❑ '� �y Capacity-� i No. Compartments Distance to nearest: Well I � Method of Dispos�a f Foundationproperty Line LEACHING LINE ❑ No. & Length of lines �(} / ,,, f FILTER BED � Total-To ❑ Distance to nearest: Well A�Foundation �� *'r Projierty Line�� + SEEPAGE PITSt] ❑ Depth SizeNumber. = itis SUMPS . C] Distance toy DISPOSAL PONDS E3 'nearest: Well Foundation.: - k rProperty Line f I.herehy 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_t' which this permit is issued, I shall not i employ any person in such manner as to Become subject to workman's compensation laws of California."Conx I or s hiring or sulciicontracting signature x 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." -� r The applicant must.cail for all required-inspections.ms.µ 0 �� . Complete drawing on reverse side. Signed Title: — Date: F R DEPARTMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection by bate ' Final Inspection by Il k 4 Additional Comments: � `� �"' '�' r . , ^^�..� - - bate -. ❑ Stk 466-6781 ❑ Lodi 369-3621 j❑ 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 FEE` AMOUNT DUE CK ' INFO: AMOUNT REMITTED CASH RECEIVEBY DATE PERMIT'NO. r - + EH 13-24IREV.'1 8sl EH 14-26 I. J