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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. AZEL i ON A� ,, STOCKTON, CA 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address //Oc�, ► t/ ! L k-0— City 1/4,{,e(Size PM Owner's Name 0 l , Address __ 1 ! ®a, Yy Z ( � 0 Phone 1 CY�k'1/�ti Address Q�Q JC � t.6 2,373 c s� �b`�6 Contractor License No. Phone ! _TYPE OF.WELL/PUMP; ' t.� .,NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION f+� SYSTEM REPAIR ❑ OTHER ❑ \ DISTANCE TO NEA S7: EPFIC TANK . SEWER LINES DISPOSAL FLD. PROP. LINE (� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,. ❑'Industria! 1 ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing � r L/-115mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _,Approx. Depth I 1 Eostern Surfac Seal Installed by Repair Work Done, of Pump �lt H.P. State Work Done Well Destruction. ❑ Well Diameter Sealing Material Itop 5(fl t -Depth I Filler Mate�.iali f Below�50j4 TYPE OF SEPTIC WORK: NEW INSTALLATION 1I REPAIR/AQDIT•ION,I I DESTRUCTION l 1 INo septic system permitted if'public sewer is h f F_ _ available within 200 feet.! Installation will'•serve: Residence 'Cmmerc al's Other 1 Number of living units: Number of bedrooms 4tit Character of soil to a depth of 3 feet:. i Water table depth SEPTIC TANK-yl"'— `; ❑ Type/Mfg _ y Capacity No. Compartments PKG. TREATMENT tPLT ❑tit 01 Method of Disposal e Distance tti-nearest: Well Foundation Property Line LEACHING LINE t ❑ No. & Length of lines Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1-1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E 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 ense a s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ an . erson in such ma er as to become subject to man's compensation laws of California."Contractor's hiring or sub-contracting signature i certifies t e following:."I certify, int pe n of a ork for which this rmit is issued, I shall employ persons subject to workman's compensa- tion law of California." f The ap licant must' f requ- d ' p eta rawing on a Sighed X Title: Date: � { FOR DEPARTMENT USE ONLY Application Accepted by ! Date - a 3 -7 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: )L ❑ 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 i i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. b' + EH13-24 IREv.t i N 5lAds w fH f4-26 i