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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y` 1601 E. HAZEL I ON AVE., STOCKTON, CA a Telephone (209) 466-6781 i. 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District.` y :. b Job Address r j Y 'L, City Lot Size PM Owner's Name Lac 4 n Address; Phone I 6 I Contractor � l Imo_Address License No..2�Phone J i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i fi 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 WILL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 1:1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ 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 Done i Well Destruction ❑ Well Diameter' Sealing Material (top 50') a Depth _ Filler Material (Belo 501 # TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Er DESTRUCTION ❑ (No septic system permitted if public sewer is P available within 200 feet.) Installation will serve: Residence !f Commercial_ Other Number of living units ,_ Number of bedro s Character of soil to.a_depth_of 3_feet: Water table depth F f SEPTIC TANK ❑ Type/Mfg - CapacNo. Compartments PKG. TREATMENT PLT. O "Method of Disposal - r Distance.to nearest:i Well �-Foundation- �i ' Property Line LEACHING LINE & 'NO. & Length of lines _ �[S '" W " '�;Tptal length/size ,. 15Pror6 ,FILTER-BED,.�. __ „� E) N- ati _ Distance to,nearest: Well � i Foundon�,. perty Line SEEPAGE PITS ❑ Depth I Size jiNumber SUMPS 11Distance toInearest: - Well Foundation Property Line 4 DISPOSAL PONDS ❑ � i I 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 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."Contractors hiring or sub-coritiracting 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." E The applicant must call for all required inspections. Complete drawing on reverse side. w - Signet) i. Title: Date: X FOR DEPARTMENT USE ONLY : Z Application Accepted „� 0 by � � .Date Area • Pit or Grout Inspection by IffZApate I Final Inspection by Date �— Z A j t r d Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 368-3621,. enface '823-7104: ❑ Tracy $35385 - -` - Applicant-'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY -DATE PERMIT''NO. 4 + EH 1 -24IREV.1/951 � EH 1428 3/ V-7