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c ry APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f � ` ' Telephone (209) 466-6781 y Pe� V PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ] \J�� N nG�~ I Complete in Triplicate) 1i�'�:v cyCG\ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.\rThis 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. R r 4 -, 1 C Job Address 6 0 City /Ie WLot Size PM LOwner's Name ` Address ,rPhone Contractor jc Address - QP License No Phone TYPE OF WELL/PUMP: NEW WELL'-n WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ #� SYSTEM REPAIR 79 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 Welt Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications p� ❑ Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ �1 I I Irrigation _..Approx. Depth J I Eastern S ace Seal Installed by _ ` Repair Work Done RX Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 7Z Depth Filler Material (Below 50') —_ TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is � available within 200 feet.) l Installation will serve: Residence .Commercial— Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth + SEPTIC TANK ❑ Type/Mfg °� CapacityNo. Compartments PKG. TREATMENT PLT. © tt Method of Disposal Distance toynearest: Well " Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size_ FILTER BED ❑ Distance to nearest: Well{'° Foundation Property Line i I SEEPAGE PITS i I Depth Size Number 'z L r 4 SUMPS til Distance to nearest: Well Foundation Property Line DISPOSAL 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 Joaquin Local'Health District. y 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:;3 certify that in[he_. performance of the work for which this-permit-is issued, !shall employ persons subject to workman's compensa tion laws of California." z`+ `[— The ap must II for all required i ction om e drawing on side. t41 Signed X Title: P S- _ Date: OR DEPARTMENT USE ONLY Application Accepted by / "'"" Date Gam. Area �J Pit or Grout Inspection by Date Final Inspection by Datecs' ��C 1 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 CK INFOFEE `MOUNT DUE AMOUNT)REMITTED CASH RECEIVED BY DATE PERMIT NQ. a.EH 13-24 1 REV. CIA. ii>1s a, EH 14.26 �L