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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone(209) 466-6781 R�, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ji y (Complete in Triplicate) J 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 141-1 �F ;x k Job Address __ �7.7� -/'� fE l� f {A 0M City Lot SizeZ34X 264 PM Owner's Name --Address -� - +- e �— - F` . � #' f�� Phone 1 i.. Contractor Address .License No.�y'j�3 Phone i i TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT p DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK AW 59,._ SEWER LINES DISPOSAL FLD. �'sFPROP. LINE ri FOUNDATION AGRICULTURE WELL OTHER WELLPITS/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 ❑ Public ;❑ Other ❑ Delta Depth of-Grout Seal '� f Type of Grout E ❑ Irrigation =Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ;- i Well Destruction ❑ Well Diameter Sealing Material (top 501 5-5 0 Depth t, Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - available within 200 feet.) Installation ' serve: Residence Commercial_ Othei G' r. Number of living units. Number of bedrooms Character of soil to a depth of 3 fe ' Water table depth ' SEPTIC TANK ❑ Type/Mfg f I Capacity No. Compartments PKG. TREATMENT PLT. ❑ el }I Method of Disposal Distance to nearest: Well Foun a Property Line_ LEACHING LINE ❑� No.. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �i SEEPAGE PITS ❑ Depth I Size Number f i SUMPS ❑ 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 taws, ander"` rules and regulations of the San Joaquin 1 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." t T The appl' ant st call for all required ' pections. Comp) to drawing on reverse side._ Signed Title: Date: Jr , OR DEPARTMENT USE ONLYf Application Accepted by } Date 7—F7 Area v 1 Pit or Grout Inspection by Date. Final Inspection by 1 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621' ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 'IFEEf INFO AMOUNT DUE i AMOUNT REMITTED SH RECEIVED BY DATE /P�E'RMIT'NO,' a + EH 13-24(REV 8H 1426