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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT1 � 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 a's PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) l � R �` r`+ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work i t gacF{tC lication is H '-- made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruls _. ��s� t n Joaquin Local Health District. r �7 14_ z t Job Address �]� � i.C.f�it�� City Lot Size PM Owner's NameAddress Phone F ~� Contractor 4 + Address QGr�d 7Y License No. �__T r # _ Phone � � a 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing t Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. D th I l Eastern Surface Seal Installed by Repair Work Done ] Type of Pump H.P. State Work Done c Well Destruction ❑ Well Diameter Sealing Material {top 50'1 4 �--� Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other { Number of living units: Number of bedrooms t� w M Character, of soil to a depth of 3 feet: Water table depth's"' _ 1 SEPTIC TANK ❑ Type/Mfg Capacity —No—Compartments PKG. TREATMENT PLT. ❑ .. _ g1 Method of Disposal n� Distance to nearest: Well Foundation Pro perty Line 1 LEACHING LINE ❑ No. & Length of lines Total length./size I FILTER BED ❑ Distance to nearest: WellFoundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS z, ._ _.; Cl Distance to nearest:. Weil Foundation. Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, and rules and regulations of the San Joaquin Local Health Di%trict. 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, f shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." The applicant must all all required inspections. Complete drawing on rev se side. Alp� Signed X _ Title: Date: �Tl� R DEPARTMENT USE ONLY Application Accepted by Date r-9"19 Area / Pit or Grout Inspection by ate Final Inspection by Date 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 IFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. j +.EH 13-24(AEV.riH6) EH 14-26