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APPLICATION.IFOR PERMIT /J `IV SAN JOAQUIN:LOCAL HEALTH DISTRICT >. t I 1601 E. HAZELTON AVE., STOCKTON, CA N e , �,, +' Telephone {209} 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C ' (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. 1062 for well/pump and the Rules and Regulations of the San Joaquin 1 Local Health District. 4 Job Address M2 T t City Lot Size PM i Owner's Name-c ! w 19 Address i Phone Contractor f+� �+ Address � ,.,�� License No. �5.1_L Phone � 9 TYPE OF WELL/PUMP—NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IRS SYSTEM REPAIR ❑ OTHER ❑ f 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 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing ❑ Domestic/Private 11 Gravel Pack ❑ Tracy "`-`�Type of Casing ' L Specifications 4� ❑ Public ❑ Other Ll Delta Depth of Grout Seal � ElIrri Irrigation TYPe of Grout 9 _. Approx Depth ❑ Eastern Surface Seal Installed by I Repair Work Done IYType of Pump �� H.P. State Work Done Well Destruction ❑ . Well- am tet Sealing Material Itop 50'} Depth Filter Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is } II available within 200 feet.) Installation will serve: Residence`i Commercial— Other Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK '^ -❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,, � , Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE _ ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance fo nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number x SUMPS ❑ Distance to nearest: Well Foundation Property Line ti DISPOSAL PONDS ❑ j 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la rules and regulations of the San Joaquin Local Health District. ws, and Home owner or licensssued, I shall not agent's signature certifies the following: "I certify that in the performance of the work for which this permit is i g; 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 tion laws of California." - P Y Persons subject to workman's compensa- tion The applicant call for all required inspections. Complete dr ing on reverse side. y l , . Signed �.f;J Titlew Date: 4 F R"DEPARTMENT USE ONLY. A Application Accepted by �� 4 Date.' i Area i d Pit or Grout Inspection A } Date Final Inspection by Additional Comments. "•❑ Stk 466-6781 ❑ Lodi 369-3621' ❑ Manteca 023-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: EniVironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE pa INFO AMOUNT DUE AMOUNT REMITTED ' C RECEIVED BY r.. .. SH DATE . —•—_-...... Z16=r. – .. PERMIT'NO + EH 13-24{REV.t/e 5) . EH 1428 - I