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APPLICATION FOR PERMIT T41r SAN JOAQUIN LOCAL HEALTH DISTRICT RACE VES 1601 E. HAZEL`TON'AVE., STOCKTON, CA Telephone (209) 466-6781 P G PERMIT EXPIRES EXPIRES 1 YEAR FROM-DATE ISSUED (Complete in Triplicate}" VlRONME�NTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereip"ald�QNpplication is made in compliance with San Joaquin Cou'My Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of,the San Joaquin Local Health District. w ��.,/9 S �"..I�ICJI�CL,., L�� "' .. city Lot Size "f #?� PM Job Address r,, ,��„ ....-� � Owner's Name Address Phone PDA i Contractor Address/ License No - 2f` Phoneo3 "`Y O TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER . DISTANCE TO NEAREST: SEPTIC TANK1 SEWER LINES '' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weell Excavation Dia. of Well Casing lit Domestic/Private ❑ Gravel Pack ❑ Tracy Type"of-Cb-sing d Specifications ❑ Public ❑ Other t 13:De1 fe .'Depth};pf GrouSeal. 1 Type of Grout ❑ Irrigation �pprox. Depth; `❑ Eastern .Surface Seal Ins%lled by r Repair Work Done ,e Type of Pump -A H,P. f %i- State Wark Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') i'-4d O Depth Filler Material`(13e10'vu'501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial— Other LA Number of living units:' Number of bedrooms ' =' Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ld , Nb. Compartments PKG. TREATMENT PLT. ❑ i tMethod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑,a..No. & Length of lines Total length/size } Q FILTER BED ❑ Distance to nearest: Well Foundation Property Line i .. 1 fi l SEEPAGE PITS ❑ Depth " Size Number SUMPS ❑ Distance to nearest: Well Foundation Property,Line. 11I 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 District. I It 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:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." t The applicant rpust call for required inspections. Complete drawing on re erse side.: Signed Title: Date: ' FOR DEPARTMENT USE ONLY Q �} Application Accepted by t Date U Area Pit or Grout Inspection by ate Final Inspection by �jlY1i Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ 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 r EE 4 ' INFO AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT'NO. + EH 13-24[REV,r/s51 p�� y `7r�g ��1.57 EH 14.28