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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT w h 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 rgoo 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NO (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work�iein des r e . this pplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welltpump and the Rules and Regulations of the San Joaquin Local Health District. 'j Job Address Q d City l'A.!Di Lot Size PM , (� � Owner's Name �j5 J' Address Phone �(�� Contractor (!�X' Ad ess 0 ojwJ ? OJL' License No. Phone TYPE OF WELL/PUMP: NEW"WIfILL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �( , 11Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications UV 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.'] REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.I 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 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number -, SUMPS ❑ 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: "1 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 hkring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I hall employ per n t to workman's compensa- tion laws of California." �] The applicant must all for all req"d d inspections. Complete drawing on reverse side. 397 x Signed X ! Title: Date: J"F r k «•,- fes' F R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date OI IF Additional Comments: U S ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I'• iFEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. r + EH 13-24 4REV-i/R 51 ,C �� EH 14-26 •-7 y �.�{•!