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it 5 I) APPLICATION FOR PERMIT li SAN JOAQUIN LOCAL HEALTH DISTRICT ,I 1601 E. HAZEL T ON AVE_ STOCKTON, CA -4 II Telephone (209) 466-6781 �I �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 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 "Y Local Health District. ,i Job Address 4a I�„ /�� ? A City Lot Size / PM E T-- � Owner's NameI Address – Phone 1 i _T1 �� T '� _ License fVo,&Z Phone 01 Contractor ^dress _ _ TYPE OF WELL/PUMP: II NEW WELL 2�, WELL REPLACEMENT E1 DESTRUCTION ❑ PUMP INSTALLATION 9 SYSTEM REPAIR ❑ OTHER ❑ . , DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLDPROP. LINE 0 , FOUNDATION ,AGRICULTURE WELL OTHER WELL AG PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �sii 5 ❑Jndustrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing ,Domestic/Private 'f6ravel Pack ❑ Tracy Type of Casing Specifications 4 &'I�j M Public !r 11 �otppzmp ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ! x. De thi�I 1 Eastern Surface Seal Installed by Repair Work Done [� pMLL7 H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is ij available within 200 feet.) Installation will serve: Residence— Commercial Other CA Number of living units: Number of bedrooms .i f Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size {� FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 1 1 Depth Size Number Q SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I, i ' 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 Dikrict. 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 compensa' tion laws of California." it The applicantAlot call for all requir inspectic . Complete drawing n reverse side. Signed X II e: Date: I� a FOR DEPARTMENT USE ONLY Application Accepted by I Date CArea Pit or spection by Da utte Final Inspection t Date�� Additional Comments: Ip i1 Q Stk 466-6761 ❑ 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 II FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT'NO. INFO r + EH 13-24 4REV.i i x sl JAS V� tf a�•�� 4417 P- Y �g23 EH 14-26