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fes` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED , fComplete-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 iri compliance with Saneoaquin 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" n!i .. � LrlPf t Job Address" iJ1p - City Lot Size '' M Owner's Name ��I1��17 Address , Phone, ess44 -Contractor t License No. Phone TYPE OF WELLlPU P: �� FNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS . SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _...-_._ _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ',;TYPE OF WEL'L-----PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial � Open Bottom ❑ Manteca r Y Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private . L7 Gravel Pack 0 Tracy^ —Type of Casing Specifications ` F1 Public Cl Other- r L1 Delta Depth of Grout Seal Type of Grout I I Irrigation .11..ApprL).:Depth i 1 Eastern Surface Seal Installed by - :i Repair Work Dane ❑ Typo of Pump H.P., i State Work Done i Well Destruction ❑ Well Diameter R Sealing Material (top 501 } Depth x Filler Material,(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION W RAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is EP available within 200 feet.) Installation will serve: Residence Commercial Number of living units: _ :_° Number 01bedroorlo _..— Character of soil to a depth of 3 feet: _k Water table depth SEPTIC TANK OType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. F, ! �{J Method of his l__ Foundation / t/ Property Line Distance to nearest: Well L� LEACHING LINE ❑II No. & Length of lines ]P= Total length/size FILTER BED- ❑I! Distance to nearest: Well Foundation 1 �- Property Line f 5 E PITS l l� Depth N ber SUMPS Foundati Cl Distance to nearest: Well on Property Line D SPOSAL 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 Jo gin Local Health District. signature. Home owner or licensed agent's signature certifies the following: "l 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 6'come 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." The applicant must c04or all required i tions. Complete dr on're ._ side. �^ - Signed X `l itle: Date: (I FO APARTMENT USE ONLY i Applica ion Accepted by _- Date '— � Area }� or t n ion by Data / Final Inspection by d�� Date_ 4 Additional Comments: ❑ Stk 466-6781 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO r CASH f +.EH 13-24 1REV.t _w { EH 14-26