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�. APPLICATION FOR PERMIT 'f S rI�,i7'Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1 f�;t t. i 1601 E. HAZE I._ON AVE., STOCKTON, CA Telephone (209) 466-6781 afi►'` PERMIT EXPIRES T 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. j Jab Address K ' •1F i j City`` Lot Size P Owner's Name 'r Address fiJ[r i ,. J;)j~�1i i Phone Contractor Lit , i"i"j N( Address �. License No. �r. Phone TYPE OF WENT/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIQN? 1 '> PUMP INSTALLATION ❑ 1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,-- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—PITS/SUMPS 2 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ DamesticlPrivate © Gravel Pack ❑ Tracy Type of Casing Specifications FI Public fl Otherfl Delta Depth of Grout Sea! T Irrigation.. —.Approx. Depth l 1 Eastern Surface Seal Installed by— Repair of Grout Repair Work Done! ❑ Type of PumpH.P; State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIRJADDITION I I DESTRUCTION I I (Noseptic system permitted if public sewer is available within 200 feet.) w j,., Installation will serve: Residence_ Commercial Other i ..Number of fiving units: Number of bedrooms Character of soils to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' PKG. TREATMENT PLT;❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE. : EJ ; No. & Length of lines Total length/size FILTER BED j ❑ ' Distance to nearest: Well Foundation Property Line E SEEPAGE PETS 1 1.; Depth Size Number SUMPS r � � � ❑.:.Distance 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 laws, and rules and regulations of the San Joaquin Local Health Di1trict. Home owner or licensad 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 fallowing: "I certify that in the pe arm ce of the work for which thisermit is issued, 1 shall employ tion laws of alif P P Y Persons subject to workman's compensa- The appli nt ri1 t c r e 1 ct oniplete drawrnom%reverse side. Signed Title: Date: I FOR DEPARTMENT USE ONLY 1 Application Accepted by "� r Date Area Pit or Grout InspaStion by Date ,. - Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 AMOUNT REMITTED' C INFO CASH . ' RECEIVED BY DATE PERMIT'NO. +.EH 13-21 IREV,1/n sl EH 14.20 i w