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f I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM'DATE ISSUED 1' = ` t. (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 Regulationa:;of the San Joaquin f ,Local Health District. f §• r�. y Job Address !!M -5:XA t —C � f City Lot Size 116 1" " ; PM ' l Address /c7 U �� _ (1/+/i Phone Owner's Name �L - r�C�/l. - - - Contractor W/ I Address License No.�-Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F] SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL- PROBLEM AREA}! CONST.RUGTION SPECIFICATIONS ❑ Industrial [-]7 Open Bottom ❑ Manteca Dia.Aof Well Excavation Dia. of Well Casing 4 :1 Domestic/Private 0.Gravel Pack ❑ Tracy Type of Casing Specifications ❑ P4 iclrc ❑ Other - ❑ Delta Depfh of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Sealing Material (top 50'i Well Destruction ❑ Well Diameter / Depth Filler Material rfBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is i g available within 200 feet.) Installation will serve: Residence_ Commercial— Other r - Number of living units: Number of bedrooms Character of soil to a depth�of 3 feet: Water table depth SEPTIC TANK ElType/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 PITS 1_11C] *K —Size Number SUMPS C] . Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1 ❑ ' K I hereby certify that I have prepared this'applicatibd'arid'that thew�kwill.:be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the S'an Joaquin Local Health District. 0 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 applican st call for I required inspections. Complete drawing on reverse side. I "Signed Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted b Date Z- 4& At a .n 9 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 RECEIVED BY DATE PERMIT"NO. INFO CASH °��7��" 9 +,EH13-24SREV.I/a51 - ( 1f EH 1426