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a C APPLICATION FOR PERMIT SAN JOAQUIN LOCALHEALTH DISTRICT I 1601 C'HAZEL7ON AVE',, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEARh!FROM DATE ISSUED i (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. It ' i [�Job Address � +� r L � City �� e PM 4 Owner's Name Address 1)1� Phone Contractor of © License No. A? 2 Phone ! �' TYPE OF WELL/PUMP-- t.N ' NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ PUMP INSTALLATION Ie t SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELLL a j OTHER'WELL PITS/SUMPS [ , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTlof SPECIFICATIONS ❑ Inndd�'strial [D Open Bottom ❑ Manteca Dia. of/Well Excavation_ : '� Dia. of Well Casing 1-1 Ind ❑ Gravel Pack ❑ Tracy Typej0 Casing t ; iN !Specifications 7 Public Cl Other ❑ Delta Depth of Grout Seal-----i f Type of Grout i I 1 Irrigation IApprox. Depth I i Ea tern t Surface Seal Installed by Repair Work Done Ori/ Type of Pump H.P. ---State Work Done Well Destruction ❑ Well Diameter Sealing Material-(top.50'I Depth Filter Material (Below 56' u TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION 1 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation wI Residence— Commercial— Other E Number of living units: bedrooms Character of soil to a depth of7��f i Water table depthr SEPTIC TANK ❑ TyNo. Compartments TREATMENT PLT. ❑ I� - thod of DisposaDito nearest: Well Foundation Property Line LEACHING LINE 17 No. & Length of lines f �M Total length/size FILTER HED I❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth SizeNumber I SUMPS (-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Ii. f hereby certify t prepared this.application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and II rules and re ations of the an Joaquin Local Health District. Home ow r or licensed agen 's'signature certifies the full g:"1 certify that in the performance of the work for which this permit is issued, i shall not employ y person in such m nner as to bec a svbjec o orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies he following: "I ce that in e m nc of work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion la sof Cali#orn! ' The ap icant m t fo ell requi d i d awing on ev l e Id . i, Signed X '� Title: � .�� II v F R DEPARTM NT USE ONLY Application Accepted by Date�� Area Pit or Grout Inspection by !� Date I�.Final Inspection by /'ti' Date II I� r Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 1�0 Tracy 835-6385 - Applicant- Return all copies to:, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IN �� p.. t 111 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH pH t EH13-24 iREV.1/n 5) i FH 14-26 . �_-Y-f7 'i II