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i ( APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /) 1601 E. HAZEL T ON AVE., STOCKTON, CA L1 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 incompliance 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.` �t , _/ Job Address (� 'V U. I�8l"�'_4�6.2 City_ ' c e 4i Lot Size PM Owner's Name / - �� t _ Address /1! fJ/� ad kA Phone ^5 � r , Contractor_ St!e / Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT, ❑•. DESTRUCTION ❑ PUMP INSTALLATION ❑ - -'SYSTEM REPAIR ❑ e OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,FLD. PROP. LINE FOUNDATION AGRICULTURE WELL -:OTHER WELL'° PITS/SUMPS _ 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 FI Public F1 Other Cl Delta Depth of Grouf=Seal'" Type of Grout 1 1 Irrigation __Approx. Depth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction O i Well Diameter _ Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION IJ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ -Other Number of living units: Number of bedrooms "'- Character of soil to a depth of 3 feet: Water table depth -,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 N Total length%size FILTER BED ❑ Distance to nearest: Well Foundation< Property Line i SEEPAGE PITS I I' Depth Size Number SUMPS i❑ 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 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st all for all equir d nspecV ns. Complete drawing on reverse side. Signed o / Title: Date: FOR OEPARTMENT•USE ONLY - Application Accepted by _ t. Date' �yL "', `� _ Area Pit or Grout Inspection by Date Final Inspectionf by `� Date Additional Comments• + �:" -�, <-/2 � Gtwi e.( z� f�JTff"� e D Stk 466-6781 ❑ Lodi 369-3621 D 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 95201FEE _ INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +.EH1 -241REV.=/Ns) EH 144-28 1790 / !CJ