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� S APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT CL..-c 1601 E. HAZE T ON AVE., STOCKTON, CA �5 i Telephone (209) 466-0781 PERMIT EXPIRESA YEAR FROM DATE ISSUED r ' ' -T--lrf r: (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 f 'I City Lot Size V X�l�.J iPM 4 . ,A Owner's Name _.. d�.:� Address Phone If Contractor I Address /2 License No. /� '-"y 1&hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 171y 1 PUMP INSTALLATION ❑- SYSTEM } I ' REPAIR ❑ OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ! ❑ Open Bottom ❑ Manteca Dia, of Well Excavatio n. Dia. of Well Casing - ❑ Domestic/Private i El Gravel Pack Ll Tracy c Type of Casin SSpecifications{ ❑ Public ❑ Other . Q Delta Depth of Grout Seal i El Irrigation _""meq Type of Grout € --Approx. Depth ❑ Eastern Surtace Seal Installed by Repair Work Done _ ❑ Type of Pump H.P. i State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ¢ Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION'❑ REPAIR/ADDITI ❑ ESTRUCTION Q septic system permitted if public sewer is avail lr`/J E a a within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet:. f - r ❑ T e/Mf` "' Water table depth SEPTIC TANK f yp g Capacity ' NoCompartments PKG.`,TREATMENT PLT. 171 .Y` ; - rt; `` •,. i tLl Method of Disposal r-y, Distance to nearest:-F' Well Foundation, Property Line L_J" _ �• I {� ;i LEACHING LINE ❑ No. & Length.of lines ^ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � J SEEPAGE PITS ❑ Depth Size o p Number F'*. SUMPS + ❑ Distance to nearest: Well Foundation -«Property Line------ #;rl 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 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-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." i The appfica must call for II requir d inspections. Complete drawing on reverse side, v �. r .l Signed Title: --�. �.- . Date: FOR DEPARTMENT USE ONLY Application Accepted'by 3 r Date Area O Pit or Grout Inspection Date Final Inspection• ' Dater' Additional Comments: ❑ Stk 466-6781- 1 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy / Applicant- Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK INFO CASH.__ RECEIVED BY DATE PERMfT''NO. + EH 13-24{REV.1/851 / `� g7-63 EH 14-29 � iod / 1�