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} i R t//37 APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL'HEALTH DISTRICT �? ; 1601 E1'HAZEL i ON AVE., STOCKTON, CA " t Telephone 2091 466-6781 P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l n /Complete in Triplicate) rt' TAI HEALTH rFi'�x` RC?,�'� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he n tl scrcal l �iiL �pypfI_arign is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Re g�l i f e an Joaquin Local Health District. � 3 � f J Job Address r C v Lot Size PM � ra Owner's Name Phone f� l Contract ss Pin License No. J Gtr Phone j TYPE OF WELL/PUMP: iii NEWWELL LL ❑ WELL REPLACEMENT ❑ / DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ i DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE= d 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. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications' ('-I Public 1-1 Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth I I stern Surf! a Seal Installed by [81 Repair Work Done '<T—y., of Pump H.P. -- .State Work r Well Destruction ❑ Well Diameter Sealing Material /top 501 I Depth Filler Material (Below 501 s TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is .t -�" available within 200.feet.) Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of bedrooms E Character of soil to a depth of 3 febt: "" Water table depth SEPTIC TANK ❑ Type/Mfg Capacity r.No. Compartments PKG. TREATMENT PLT. ❑ J Method of Disposal —Distance-to Property-Line. LEACHING LINE ❑ No_ & Length of lines FILTER BED ❑ Distance to nearest: Weil Foundation Property Line " SEEPAGE PITS l I Depth Size Number SUMPS Ll 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. Homeowner or ' d 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 rson in su manner as to become subjec . workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t following: "I c if .that in the o a o the wo hich this permit is issued, I shall employ persons subject to workman's compensa- tion law of California." The a licant st call f all re ed ' o . Comp to drawing o r side Signe XTitle: Date: FA—PEePARTMENT USE ONLY Application Accepted by Date�� Area Pit or Grout Inspection by Date Final Inspection by Datef�L�-Bg Additional Comments: I ❑ 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, Silk., CA 95201 FEE INFO AMOUNT DUE AM NT REMITTED CASH RECEIVED BY 11 N / DATE PERMIT NO. +.EH 13-24(REV.1 i H 5) S�� //� p// EH 11-26 ✓✓✓ ( rU / �