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APPLICATION'FOR PERMIT C) u4 erDb SAN JOAQUIN LOCAL HEALTH DISTRICT i r�" co v r ��//// 1601 E. HAZELTON AVE:, STOCKTON, CA Telephone (209) 466.6781 f 02 F7C ri� Y"` rPERMIT EXPIRES1 YEARFROM DATE ISSUEDC'6 (Complete in Triplicate) Application is heuin Local Health District for a permit to construct and/or install the work herein described. This application is m ty 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 City Z Lot Size PM ' Owner's Name ddress n Phone 1 3 --7 ,Z Contractor's Name Z cense-No. !J Phone �— TYPE OF WELL/PUMP; W WELL,>(,- WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER ❑ ` - DISTANCE TO_NEAREST: SEPTIC TANK _/SD SEWER-LINES —.DISPOSAL"FLD, _-- PROP._LINE__.�_ _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private XGravei Pack ❑ Tracy Dia. of Well Casing 'Type of Casing �� Specifications X Public ❑ Other ❑ Delta Depth of Grout Seal 11 Irrigation Type of Grou ---Approx. ❑ Eastern Surface Seal Installed by Repair Work Done '❑ Type.of Pump'.�. H.P. Well Destruction ❑ Well Diameter '" State Work Done Sealing Material (top 501) Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence— Commercial Other available within 200 feet.) Number of living units: Number of bedrooms' Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity No..Compartments PKG. TREATMENT ALT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 t LEACHING LINE' ❑ No. & Length of lines 1 FILTER BED Total length/size ❑. °Distance to nearest: Weil Foundation l Property Line SEEPAGE PITS Depth Size �-SUMPS - Number ❑ Distance to nearest: -'Well' µ -_,�_-- = Foundation Property Line A DISPOSAL PONDS• ❑ 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. 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."Contractors hiring or sub contracting signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's com nature tion laws of C itornia." pensa- The applicant ust call for all r uir inspections. omplete drawing on rave se si e. Sign 9 Title: Date: 1� FOR DEPA ENT USE ONLY # Application Accepted by Date l Pit or Grout Inspection by Date Area Final Inspection by Date Additional Comments: ipvy n kv4 Ok w, ra+� t R'1c LA Yav +. t — r E2 Stk 466-6781 ED Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 .i FEE AMOUNT DUE AMOUNT REMITTED r( INFO ..�+� CASH RECEIVED BY DATE PERMIT N0. 3 + EH 1}24 IAEV.101831 Li Q� EH 1428 --- ---- ii... . . r •-r G/{ r