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r1 APPLICATION,'FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ��Cu�� r 1601 E. 'HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1-4ONQ ,-A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n (� (Complete in Triplicate) s 1 . ` 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 Local Health District. T Job Addressr F ' City -"t '"ry Lot Size _ _PM Owner's N2me- ydress �� - POone � �— Contractor / z Address _ License No.,& Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN i❑\ DESTRUCTION.❑,.. a PUMP INSTALLATION 0 SYSTEM'REPAIR-❑ OTHER ❑x DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r , ❑ Industrial- ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '1 ❑ Domestic;Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4 ❑ Public ❑ Other "i ❑Delta Depth of Grout Seal Type of Grout ( C1 Irrigation �4pprox. Depth ❑ Eastern Su face-Seal-Installed-b r Repair Work,Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t Filler Material IBelow 501 (bN,, TYPE OF SEPTIC WORK: 'NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION- INo septic system permitted if public sewer is "1 available within 200,feet.) ' ) Installation will serve: Residence_ Commercial_ Other • d Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: table depth s' SEPTIC TANK ❑ 7 ype/Mfg Capacity . No. Compartments PKG. TREATMENT PLT. ❑ /�� Method of Disposal Distance to nearest: Well Foundation._ Property Line ` tLEACHING LINE 0 No. & Length of lines Total length/size . 't FILTER'BED ❑ Distance to nearest: Well # Foundation Property Line r t f SEEPAGE PITS Q Depth Size r Number + SUMP's ; LlDistance'to nearest: Well Foundation Property Line k DISPOSAL PONDS 0 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. 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,pe sons subject to workman's compensa- tion laws of California," t The ap )-cant t call for all required inspections, Complete drawing on reverse side. Signed X Title: a Date: 001 i FOR ARTMENT USE ONLY Application Accepted by �_ Date Area . r. Pit or Grout Inspection by Date Final Inspection by Date 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ 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 INFO AMOUNT DUE E AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT NO. + EH'1 -24IREV. EH 14-28 .,. .. _. i