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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i i. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t 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 City c dG Lot Size PM Job Address 1 ' Address Phone Owner's Name- - ,. _ �� f�� P-0 j 55,11d,4--phone _� (Ps { Contractor^ Address ! License No. I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI-D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing F-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private 17 Gravel Pack ❑ Tracy, yp g Type of Grout ❑ Public L3 Other ❑ Delta Depth of Grout Seal ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 rDepth Filler Material (Below 501 ` I �} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ aNailabllerwithine200 feet.) ff public sewer Is Installation will serve: as dence Commercials Other Number of living units: Number of bedrooms 3 Water table depth k Character of soil to a depth of 3 feet: Capacity ' No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ � Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines To�allength/size 6 FILTER BED ElDistance to nearest: Well-Sj — Foundation_E v Property Line SEEPAGE PITS E3Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ (` 1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws-and r 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, I shall not employ any person in such manner as to become subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature r 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." I The applicant must call for all required inspections. Complete drawing on reverse side. F Title: Date: Signed FOR DEPARTMENT USE ONLY /� Date _�` 1` Area kApplication Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: Ll66- Stk 46781 ❑ 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 3.5201 FEECK RECEIVED BY DATE PERMIT•'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH i + EH 13-24 IAEV.7/e51 O�FTpoY EH 1428