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. i r° f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. G 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PAYMENT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in'Triplicate) �yf� Application is hereby made to the San Joaquin Local Health District for a permit to construct and or install the work h {fie tie 1 application is I made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weNpump and the Rules a Regulations 401 N �o�th�eALjHaquin Local Health District. ! „Pa RVICES �//�/ �,� PFRMI�ISE "Jobp g S -" TA cit Lot Size PM Address } Phone ` �yyl uLq ti , n Address Owner's Name fid, Address Contractor Pt5s License No, 02�—Phone DESTRUCTION ❑ �I -5-4 uJA+e-r r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i PUMP INSTALLATION ❑ - - _ - -SYSTEM REPAIR ❑F OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TAN K. ,��'..— SEWER LINES ' DISPOSAL FLD.L��- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type Specifications T r Domestic/Private )d Gravel Pack )4 Tracy yp of Casing� QType of out ' ["l Public C1gOther F1 Delta Depth of Grout Seal — z yp �- I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump N.P. State Work Done _ Well Destruction 171Well Diameter Sealing Material Itop 501 Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADOITION l I DESTRUCTION I I (No septic system m per fe titled it public sewer is _ installation will serve: Residence`._Commercial - [ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TAMC El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal N Distance to nearest: Well Foundation Property Line LEACHING LINE 1T1 Na. & Length of lines Total length/size r Property Line FILTER BED ❑ Distance to nearest: Well Foundation p Y SEEPAGE PITS I l Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ h 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, 1 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 work for which this permit is issued, I shall employ persons subject to workman's compensa ' tion laws of California." I The applicant ust cat]for all requir inspecti S. Complete drawing on ry4erse slde. o Signed X Title: ��- fl � - Date: ' R DEPARTMENT USE ONLY Date Area Application Accepted by �'�"L'"� Ie Data I� Fina! Inspection by Date Pit or Grout Inspection by 1I Additional Comments: 0-1�1 f D Id we( as s� Aa(� l J CQSI ❑ Stk 466-6781 0 Lodi 369-3621 ❑ M teca B23-7104 ❑ Tracy 835-6385 11 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMC?!INT REMITTED CASH RECEIVED 9Y DATE ' PERMIT'NO. INFO ♦.EH 13-24(14 EV.I/x 51 EH 14-28 - s'