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r - APPLICATION FOR PERMIT . W' j "I ( � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZELTON`�4)E„ STOCKTON, CA " 1 -5 ,• 7 . ;. Telephone 120911'466-6781 ti l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Vxy O. i i i�CAL1110ES ~� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 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 Districts Job Address Cit of Size PM j 70-3q Owner's Name r$ 4 Address ed Phone If �( a Contractor ' Address l E License No. A 7 Phone C� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑ Industrial 0 Open Bottom ❑ Manteca Dia.-of Well Excavation Dia. of Well Casing El Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications r I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx.pDept 1 I E stern Sriace Seal Installed by _ F Repair Work Done Ll- Type of Pum H.P. f/ State Work Done E Well Destruction ❑ Well Diameter Sealing Material (top 50'1 R Depth � filler Material (Below 501 TYPE, OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 111 DESTRUCTION I l (No septic system permitted if public sewer is + 1 available within 200 feet.) Installation will serve: Residence _ - Commercial— Other j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth V . SEPTIC TANK ❑ Type/Mfg !Capacity No. Compartments l PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well FourFdation Property.Line LEACHING LINE ❑ No.-& Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Wellb Foundation Property Line -- - - �_ _ p SEEPAGE PITS II Depth Size P -Number j � __ r SUMPS ❑ Distance to nearest: Well Foundation �.s Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be donto naccordance with'San Joaquin county ordinances, state laws, and rules and reguI do f the San Joaquin Local Health District. ' Home owner icensed nt's signature certifies the following: "I certify th tin the pert�mbnce of the work for which this permit is issued, I shall not employ apars in such ct anner as to beco subjeorkman's compensation laws of California.;' Contractor's hiring or sub-contracting signature certifie he follo ng: "!ce fy at'in th pe r ce f t e w 'which thi rmit is issued,I shall employ persons subject to workman's compensa- tion t sof Califo nia.':.� ,�&r�� t�-� The pplicdnt mus cat) al regwre •gins plate- rawing-on,r Sign X Title: Wry �- Date: 4 Fa-R'DEPARTMENT USE ONLY Application Accepted by 9� TAS Date Area Pit or Grout Inspection by ✓ Date !Final Inspection by Date_/1.2- Sr Additional Comments: ❑ Stk 466=8781 ❑ 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 CK INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 1321 fREV. EH 11-28