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• w APPLICATION'FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 ,11PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Complete in Triplicate) Application is he,eby 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 we111pump and the Rules and Regulations of the San Joaquin Local Health District. Y f City / , Lot Size PM I Job Address 76 j Phone Owner's Name "' Address Contractor r_ oAddress R License No. Phone_ f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -� PUMP INSTALLATION © SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEARE51: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE [ FOUNDATION AGRICULTURE WELli OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation — ..Approxi Depth I 1 Eastern Surface Seal Installed by - r Repair Work Done ❑ Type of Pump H.P. State Work Done r N Sealing Material Ito 50'1 Well Destruction ❑ Well Diameter 9 P Depth } 4 Filler Material I Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATI N I I REPAIR/ADDITION 13 DESTRUCTION l 1 (No septic system permitted if public sewer is a r available within 200 feet.) t Installation will serve: Residence"�-._ Commercials"=- Other— Number ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:. Water table depth ` SEPTIC TANK ❑ Type/Mfg '+=• Capacity No. Compartments d t PKG. TREATMENT PLT. ❑ i. - _ 'l../ Method of Disposal Distance to nearest: Well; Foundation �[/' Property Line. -.- LEACHING LINE (I No. & Length of lines Total length/size —.__ .� FILTER BED EI Distance to nearest: Well Foundation Property tine SEEPAGE PITS I 1 Depth ' Size Number SUMPS Cl Distance to nearneatest: Well ' Foundation Property Line r DISPOSAL PONDS ❑ �� - 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 i 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 Iaws-of-California.'�C6rnractbr.:s.hiring or-sub-contracting signature rr 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." The applicant must all for all re fired yzspections. Complete drawing on reverse side',.,;;„ Y Signed X . -�/� lea Title: L✓ (]ate: %��' • FOR DEPARTMENT USE ONLY— Date _ - - ,•"` , Application Accepted by ~ � SDate Area ` 3 I Date Final inspection b Date f Pit or Grout Inspection by f•` I Additional Comments: ! { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63851- Applicant 35-63851Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l � INFO MOUNT DUE!, AMOUNT REMITTED CASH RECEIVED BY• DATE PERMIT'NO. �......4. ♦ EH 13-241FtEV.I/R5) / 0"L�/.' r I03r�. - J��"r/O Qt7 � �fa EH 14-28