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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT CA\10-4 1601 E. HAZELTO*AUE., STOCKTON, CA Telephone (209) 466-6781 ;�.Alt �0' 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .�� >1 S (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereli his application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rulesiq�Ft' ns of the San Joaquin Local Health District.. Job Address W A4 44 Au., City Lot Size PM Owner's Name -S -Press 9 Phone Contractor t vn Address License No.r(0 2-3 73 Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM,-REPAIR,❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK k SEWER'LINES' \ = �� DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/-SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial T ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E) Domestic/Private ❑ Gravel Pack: , . �❑ Tracy Type of Ci�sing Specifications I711 Public Ll Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation ----, - Depths II I Eastern 5� ce Seal Installed by - Repair Work Done Lr�l Type of Pump H,P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 if Depth Filler Material l8elow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I 1 JNo septic system permitted if public sewer is available within 200 feet.) I G Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms t N i r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ j I i Method of Disposal t y Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines ___- Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line 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 rules and regulations of the San Joaquin Local Health Di1trict. + 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 perso suc ma r as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f wing: "I certify t t in the performance oft ork for w ' s permit is issued, I shall employ persons subject to workman's compensa- tion lawsCalifornia." v i The app)cant must It for r uired i pe pl a ra ng on rev r si Signed X itle: Date: R DEP TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by 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 CASH / *.EH 1 3-24{REV,r/w 51 �S ( EH 1426 '� �S