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... f APPLICATION FOR PERMIT Y SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA k Telephone (209) 466-6781 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. t City Lot,Size PM Job Address r r 9 q—�f 7 5P d V1S Address Phone Owner's Name � . // ' Contractor Address k A ' License No/6 ZPhone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUF E-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 r S ecifications Q Domestic/Private ❑ Gravel Pack ❑ Tracy .Type of Casing ,P_ ('l Public - f} Other f l Delta Depth of Grout Seal –art Type of Grout I Irrigation- _.-Approx..Dep h l I Easter 'Su ace Seal Installed,by� State Work Done Repair Work Done V Type of Pump H.P. Z �---.� k Well Destruction ❑ Well Diameter 11 Sealing-Mater�top 501 Depth _ _- Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALL:AT16N I1 REPAIR/ADDITION l 1 -DESTRUCTION l 1 (No septic system permitted if public sewer is*•., available within 200 feet.I '. Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth .--r 1JSEPTIC TANK E] Type/Mfg Capacity No. Compartments Com PKG. TREATMENT PLT. Els Method of Disposal i Distance to nearest: Well Foundation: ""` Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth I Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared thisI'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 persons subject to workman's compensa- tion laws of California." ' i The applicant ust II for all r quired'ins ctions. Complete drawing on reverse side. f Signed X, " [/title: Date: FQRWEPARTMENT USE ONLY Application Accepted by ' Date Area q 57 Pit or Grout Inspection by Date Final Inspection Date by ^(U I 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 kCK 9 INFO AMOUNT DUI AMOUNT REMITTED CASH RECEIVED BY DATE (PERMIT ND. ♦.EH 13.24 IREV.i H51 CH U-28