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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM ryg-� Ufa ��F a3� S C AY42��g Phone Owner's Name � Address �__ Contractor��.L� . _dO( g«P Address License No. ��vxli �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ •"%. PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 5, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /Specifications r 11Public ElOther ❑ Delta Depth of Grout Seal v Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done (' Well Destruction ❑ Well Diameter Sealing-Material (top.50'•) Depth '* Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is n Navailable within 200 feet) Installation will serve: Residence1g, Commercial— Other - -Number of-lirririg units: NOftiber of16edrooms_4L. Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg RIL )11 Capacityt (_No. Compartments O PKG. TREATMENT PLT. ❑ Method of Disposal Z r DistP ance to,nearest: Well Foundations Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well e0;0'b Foundation 4ZI Property Line SEEPAGE PITS ❑ Depth• Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ e i 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, 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 work fpr which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." - Y The applicant must call for requi inspect s. Complete drawing on reverse side. Signed X W Title: Date: FOR , FOR DEPARTMENT USE ONLY p Application Accepted hy" ' , =1['!lrvl/� 'Date �" Area Pit;or,Grout Inspection by Date i ""` Final Inspection by Date Additional Comments: : - ❑ Stk 466-6781 El Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# Pf .RECEIVED BY DATE PERMIT'NO. INFO ASH . +EH13-24 1REV.7/e.5)-, - '�w„ •� �. "•t 3i EH 1426 - ��C�