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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `"c d (Complete in Triplicate) s 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 Ryles and Regulations of the San Joaquin Local Health District. r :t � { Job Address i City Lot Size PM - -Owner's Name [/�� 1'bldress �� -Phone 4 - - - -mow - ate- Contractor Address Qt__� �� License No>� _r' ''hone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION ❑ f- SYSTEM REPAIR ❑ OTHER-❑ DISTANCE TO NEAREST: SEPTIC TANK .-SEWER LINES DISPOSAL FLD. PROP. LINE , FOUNDATION AGRICULTURE WELL _ _OTHER WELL,_, PITS/SUMPS ; 1 INTENDED USE TYPE OF WELL PROBLEM AREA: CONSTRl1CTION SPECIFICATIONS M� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of,Well Excavation Dia. of Well Casing ' IF m ❑ Doestic/Private ❑ Gravel Pac ❑ Tracy Type bf,Ca§ing Specifications ❑ Public _ LJOther _ El Delta Depth sof Grout Seal t. }- °. Type of Grout p ' ❑ Irrigation `r _�S ' AppcaxJDepth ❑.Eas_te�n ) Suiface S al liistalled f Repair Work Done ❑ Type of Pump s f' ,�4 H.P. State Work Done Well Destruction ❑ %1611 Diakrieter„ =- `i'-='t'',Sealin.g Material (top_50'1 , Depth Y Filler;Material IBelow.501) - �+ l TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRl1GTlON ❑ (No septic system permitted if public sewer is l € r I � � ✓ �^�`available"within_`200feet.) Installation will serve: Residence _ Commercial Othei.'= t►" x t' ` Number of living-units:-Number of^bedrooms- =!D Character ofsoil to a depth of 3 feet: ~ Water table depth 0 SEPTIC TANK �. Type/Mfg Capacity f. No. Compartments PKG. TREATMENT PLT. ❑ 4Method of DisposaliWav Firl D Distance to nearest: •Well Foundation > Property.Line \ i LEACHING LINE ❑ No. & Length of lines t. Total length//site' s f ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line j r SEEPAGE PITS ❑ Depth Size Number SUMPS { ❑. Distance to nearest: Well Foundation Property Line_ Y �` DISPOSAL PONDS ❑ 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 I rules and regulations of the San Joaquin Local Health District. ; `7-r Home owner or licensed agent's signature certifies the following: "I certify that in the performance-6f 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all rhouire d ' _-N Complete drawing on reve i e s . 1 I 'T Signed' Title: Date: ." FOR DEPARTMENT USE ONLY i Application Accepted by cw..-t► �. s Date ,�"(�Zel- S Area Pe y p Yc.4� �b'9-Qi5 -Pit or Grout Inspection b °� Date " Final Inspection b �.. - u�+ to -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 A 11 1A FEE AMOUNT DUE', AMOUNT'REMITTED ' CK# `� RECEIVED 13Y DATE PERMIT"N0. 1 INFO " CASH , + EH 13-24;REv.I/as) �t � EH 1426 '�\ _ j� ti