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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT awaI 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED ? I � (Complete in Triplicate) At- HEALTH �1Vlt�d`�I�Application is is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worher�ieaf[t;e :�h+ts�gppation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules andel Bqu aUons of the San Joaquin Local Health District. > Z-1 f Job Address Owner's Name Q-, t a S4S_tr]^ Phone 02.7 Contractor dtlress License No,�� 14Pho41 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 PublicCl the, 171 Delta Depth of Grout Seal Type of Grout I I Irrigation -Apprax. De h -i astern Sytrf Seal Installed by - Repair Work Done Type of Puml,77ALVV H.P. _(/ 4 State Work Done _ Well Destruction D Well Diameter __Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION"Ll REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: t Number of bedrooms -^� Character of soil to a depth of 3 feet: Water-table depth SEPTIC TANK ❑-*Type/Mfg '""""T "Capacity �` * „ No. Compartments Y PKG. TREATMENT PLT- ❑ y r.. Method of Disposal Distance to nearest: Well .Foundation Property Line .'t a .'t• f., LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line " y SEEPAGE PITS i I Depth Size R Number. " SUMPS LlDistance to nearest: . Well Foundation Property Line "- 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 lawspand rules and regulations of the San Joaquin Local Health District. Home owner or li ag 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 p on in such man or as tAo be orae subje workman's compensation laws of California." Contractor's hiring or sub=contvacting signature certifies the ong: "I certif hat in th rma a "the work to which this permit is issued, I shall employ persons subject to workman's compensa- 4 tion laws(�It�iif`oirrnia.' The appli all req t eta drawing o v side. ��r ! �J- Signed X Title, % Date: LLJY FOR DEPARTMENT USE ONLY ` -27 Application Accepted by Date Area �- 1 '- 9 �1A� Pit or Grout Inspection by . Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 r + EH 13-24(REV.I/Hs) EH 14"2e