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.. 4 t f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 1. Fr1 I PERMIT EXPIRES 1 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 he 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. . *; . II , , -.r _ .07 Job Address 05 S1 City ize PM Owner's Name _ � �^_may Address, V < wPhone 2 Contractor/ * Address License No �t / Phone/ —392 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L] ' 3ti PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! •. � T% DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4, ❑ Industria! ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy, j . Type of Casing Specifications O Public ❑ Other " ❑ Delta DepthofGrout Seal Type of Grout _._ k ❑ Irrigation Approx. Depthi '{ Eastern Surface Seal Installed by Repair Work Done ❑ T p §" t Type of Pum I H.P.HP3 State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') 1 l Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public sewer is �� available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg , Capacity:12,6 No. Compartments PKG. TREATMENT PLT ❑ Method of Disp sal Distance to nearest: Well Foundation Property Line ! LEACHING LINE o�& Length of lines QQ tel length/size yN { Y A FILTER BED ❑ Distance to nearest:, Well Foundation property Line r ;� SEEPAGE PITS ❑ Depth t ze ., or SUMPS-'❑"`Distance to nearest: We Jation Property Line DISPOSAL PONDS ❑ f 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. 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,cdmpensa ) tion laws of California." i� k The applica must call fo II requir d inspections. Complete drawing on reverse side. �•,� h Signed w Title: I 1 Date: DEPARTMENT USE,ONLY Application Accepted : Date r 6 Area „ r Pit or Grout Inspect y Date Final Inspection by \ pie T L t� , 3 Additional Comments: ❑ Stk 466-6781 i ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835463 1 Applicant Return all copies to: Environmental Health Permit/Services 16.01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 § ! i r FEE JrY� AMOUNT DUE I AMOUNT REMITTED CK INTO CASH RECEIVED BY DATE PERMIV NO. i + EH 1344 1REV.1/e 51 �p,o y /,r Lw ' -EH 14-28.�s;..r..-+. .e;...+.w... .�.�.... .� -r �..�., .,,..,.'..,v /.°l� ........rte,_ f/i /ice