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�r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES TYEAR FROM DATE ISSUED RECEIVEU (Complete in Triplicate) ALS� � Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the work h�resred� application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t 16GC►BR�ktrti�r�s�of,the�Styp quin Local Health District. �7 PERMIT/SERVICES tl Job Address -DRQ/ /�/Y I�� City r Lot Size PM r Owner's Name 0Ms 444 Phone i r Contractor cess S• License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES =" DISPOSAL FLD. — PROP. LINE r FOUNDATION lGi AGRICULTURE WELL OTHER WELL PITS/SUMPS 1NTElJpE13FUSE ""'TYPE OF-WELL _'PROBLEM AREA -CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E) Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"I Public 17-1 Other Cl Delta Depth of Grout Seal Type of Grout_ I I Irrigation —.-Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done C7 Type of Pump T H.P, State Work Done _ Well Destruction —)& Well Diameter _ Sealing Material Itop 50'?I Depth Z Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I I {No septic system permitted if public sewer is 1 available 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: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG: TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PUTS { I Depth Size Number SUMPS D. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di"strict. Horne 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic s II r all r ired inspections. Complete drawing on r rse sid _ Signed X Title: Date: F DEPARTMENT US ONLY f Application Accepted by Date Area rlr Pit or Grout Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK 41 RECEIVED BY DATE PERMIT'NO. INFO ,�,QQ�� CASH �.EH 13-24IREV.tirtisl V0 7r EH 14-29 r i E