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5S j APPLICATION-FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.STOCKTON, CA �- Telephone (209) 466.6781 � ,,;�,, iao " I PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED a I 1 (Complete in Triplicate) a ' rs,r._ 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 Rules and Regulations of'the"San Joaquin Local Health District. T Job Address dti,/ e. ]� a City Loi Size J PM u 1 ' Owner's Name Address 4! Phone S's� Contractor � Address f �j License No. Phone TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 j Dia. of Well Casing I ❑ Domestic/Private C7 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth 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 Well Destruction ❑ Well Diameter Sealing Material (top 50') Y '" ' Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence Commercial— Other -1 Number of living units: Number of bedrooms ✓ Character of soil to a depth of 3 feet Water table depth -w SEPTIC TANK Type/Mfg -" Capacity _ No.Compartments PKG.' TREATMENT PLT. ❑ r f Method of Disposal 4 Distance,to'nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size •` FILTER BED ❑ Distance to nearest: Well k Foundation Property Line' 4. j SEEPAGE PITS ❑ DepthSize I Number —' SUMPS ❑ Distance to nearest: Well ! Foundation Property Line i; DISPOSAL PONDS D ; 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 f rules and regulations of the San Joaquin Local Health District. # ; 4 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,1 shall employ persons subject to workman's compensa- tion laws of California." r : The applicant t call for all requ' inspections. Complete drawing on reverse side. i Signed X "L Title:' - Dat f e. FOR DEPARTMENT USE ONLY 4 ° Application Accepted by Date Area 1 I Pit or Grout Inspectio 3 Final Inspection by Dat T v Additional Comments: 9;ih4 ° ❑ Stk466-6781 ❑ 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 1 - FEE AMOUNT DUE AMOUNT REMITTED P INFO CA RECEIVED BY GATE PERMIT'N0. t + EH 13-24{REV.iias) �Q EH 142810Jq.5 e i