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x + ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.T ON AVE., STOCKTON, CA 'Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED } (Complete, in Triplicate) f 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 I 'Local Health District. � Illi ,,��, a SIV, Job �. . Address City Lot Size PM yOwner's"NaPo fine /t �JAddress Phone i Contract ok r'�� 'Cb Address `•0. OY `�{v� License No a as G Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1.2 PUMP INSTALLATION [J �3.. ;,__ t� SYSTEM REPAIR ❑ - OTHER' '❑ A t DISTANCE TO NEARES IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k FOUNDATI AGRICULTURE-WELL OTHER WELL { PITS/SUMPS INTENDED USE TYPE OF WELL PRO REA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca. f Well Excavation Dia. of Well Casing ~r ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Cas, Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work bone + Well Destruction ❑ Wefl Diameter Sealing Material (top 50'1 Filter Material (Below 50') Q� w TYPE OF SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 festa ' Installation will serve: Residence� Commercial y� Other j Number of living units: >r Number of edrooms kCharacter of soil tole depth of 3•fe t: Water table depth SEPTIC TANK C9 Type/mfg;_ Capacity�ZO� No. Compartments PKG. TREATMENT PLT. ❑ } Method of Disposal f Distance to nearest: { Well Foundation_.._�` Property Line LEACHING LINE io. & Lengthof li es Total length/size v FILTER BED ❑ Distance to nearest. f Well Foundation Property Line i L,( I 'C, SEEPAGE"PITS „. ( Depth Size - Number �-C ' SUMPS ❑ Distance to nearest: Well DISPOSFoundation Property Line G AL PONDS + ❑ I hereby—certify that f hev repared 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 license d,agent's-signature-certifies-the-followin �F I/ � g: "I certify that in the performance of the work for which this employan permit is issued, I shall not � y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies tke-followingri;I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- i tion laws of California." _ The applicant, ust call fa II r uired inspections: Complete drawing on reverse sid Signed X Title: Date: FOR DEPARTMENT MENT USE ONLY '7 Application Accepted ey r �I s Date f ¢� ' Area: Pit or Grout Ins L r f pection by� ---Date Final Inspection by Date h - ' Additional Comments: iJ d Sik 465-6781 �. _ O Lodi"389 3fi21— �vO Mlanteca'823-7104 ❑ Tracy 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 INFO CASH DATE PERMIT'NO. I+ EH 13-24(REV.F/A5) �� •U� _ .. EH 1429 I w r