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l APPLICATION FOR PERMIT SAN JOAQUINrLOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 s 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.E-19 for sewage_ or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address F city I Lot Size PM Owner's Name " a Address !71S, Phone mil. mad Contractor's Name License No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E1 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' , Dia rof Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Z*.Type of Casing I Specifications ❑ Public { ❑ Other; ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �•�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 71 —Type of Pump H.P. { State Work Done Well Destruction Well Diameter- t Sealing Material (top 50') I "� Depth Filler Material (Below 501 .. � STYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is '} k available`ireithin 200 feet.) Installation will serve: Residence Commercial Other Number of livingunits:_C_— '-V- '� 4`y - ""��-� t` mber of bedrooms- Character of soil to a depth of 3 feet: ~'" � 4 SEPTIC TANK ❑ Type/Mfg r4 a Water table depth s� �� - Ca aci DO" a+ " p ty1� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well J_&��-_t Foundation 0} Property�FLine_ 7 LEACHING LINE ❑ No. & Length of lines . Total length/size` _ Y FILTER BED ❑ Distance to nearest: well FoundationY Property Line I a SEEPAGE PITS ❑ Depth Size F Number { SUMPS ❑ Distance to nearest: Well Foundation t 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,'l 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 applicau call for all i ed inspections. Complete drawing on reverse side. Signed Title: Date: FOR D ARTMENT USE ONLY / { Co Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE qP'E++RMIT"NO. + EH 13-24 IREV.101831 FH 1428 {L vv I (1 !