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1/A �J`6 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 661 h 1601 E. HAZE:T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 Ir1^ r �(: :PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "r ( 1 � (Complete in Triplicate) scN � Application is hereby made to the San Joaquin local Health District for a permit to construct and/or install the work herein, Le Rf'bCs a�1JJoaq is �ht`�aa made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a i l' n oaquin Local Health District. Job Address City Size PM 7 g . 20's" Owner's Nam tlrt1 Phone Contractor ddress License No./h23Z -Phone TYPE OF WELLIPUMP: NE, WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ N- SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' J Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I`i Public C Other C1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth ( I JEastern Surface Seal-Installed by - In Repair Work Done �k? Type o9Pumf H.P. r State Work Dor1e �+�} Y Well Destruction ❑ Well Diameter: Sealing Material (top-501 50 Depth Filler Material (Below 501 M f TYPE OF SEPTIC WORK: NEW INSTALLATION ll REPAIR/ADDITION (.11 DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) } Installation will serve: Residence_j' Commercial_ Other $Z Number of living units: Number of bedroomsg� Character of soil to a depth of 3 feet:. Water table depth SEPTIC TANK ❑ Type/Mfg k { Capacity No. Compartments f PKG. TREATMENT PLT. 11 f ! Method of Disposal 1v Distance to nearest: Well / !foundation Prooerty.Line LEACHING LINE 01-No. & Length of lines Total length/size FILTER BED ,"f] Distance to nearest: WellP Foundation Property Line , SEEPAGE PITS I I Depth i Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ti I hereby certify that I have prepared this application and that the work will be donein accordance with San Joaquin cbunty ordinances, state laws, and rules and regulations of aquin Local Health District. Home owner or lic ed agent's sig tuie certifies the following: l certify that in the performance of the work for which this permit is issued, I shall not employ any pars in such manner as o became subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the to wing: "I certify that i th rformance of a work f hich this rmit' issued,I shall employ persons subject to workman's compensa- tion laws of alifornia." ! I The applica t must call for all uire inspecti n re r s' } Signed it *1ta: FOfMEPARTMENT USE ONLY Area ApplicationApplication Accepted by Date — �} 5, Pit or Grout Inspection by Date Final Inspection by DateG�' U Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED "CA RECEIVED BY []ATE PERMIT'NO. INFO r , ♦.EH 13-24(REV. EH 14-26 r