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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. k1 Job Address`� � City S-ZLot Size PM Owner's Name Address E - - on Contrac-toAress 11 License NX .3! F Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST:-SEPTIC TANK- "-" " `^'SEWER LINES# DISPOSAL FLD. PROP. LINE I i FOUNDATION AGRICULTURE;WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE-OF WELQII J PROBLEM AREA CQNSTRUCTION SPECIFICATIONS t T- ❑}Industria! ❑ Open Bottom 171 Manteca Did!of Well Excavation Dia.of Welf Casing-" ❑;Domestic/Private ❑ Gravel Pack ❑ Trac Type ' Tracy ype of Casing Specifications 'i-] Public ❑ Other ❑ Delta Depth of Grout Seal Type 6f Groot b I li Irrigation _..Approxi Depth I i Eastern Suiiace Seal_-Installed by r Repair Work Done' L7--Type-of Pump H.P. i' State Work Done Well Destruction ❑.. -Well Diamdter Sealing Material (top 50') �nJ r *x Depths`s Filler Materia, low `, LA S TYPE OF SEPTIC WORK:- NEW-INSTALL TION (I REPAIR/ADDI DIV DEST UCTION l f(No septic system permitted if public r is avai ble'witht 200 fe E, Installation will serve: Residence=' Commercial Other ; r v Number of living units - Number of bedrooms ! Character of soil to'a depihof 3"feet:�"` Water able depth SEPTIC TANK ❑ Type/Mf j � ��. 9 � Capacity - C112 No. Compartments Y_ PKG. TREATMENT PLT. ❑ Method of tills' Distance to nearest: Well sLll. Foundation-J3C _ rope y ine LEACHING LINE ❑ No. & Length of lines 6 + Total length/size 41 FILTER BED ❑ Distance to nearest: Well oundation fb,-,- Property Line :SEEPAGE PITS I I Depth Size _j Number , SUhAPS C1 Distance to nearest: Well oeO41 'FQndation Property Line DISPOSAL PONDS' ❑ rt--�:. - 3 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. -tI 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature; 4 certifies the following: "I certify that in the performance of the work for whicti this permit is issued,'I shall employ persons subject io-workman's compensa- tion laws of California.'_ The appiicarl ust call forquired ins ctians.'Complete,araw_Ong on reverse side. q Signed X Title: . r `+ Date-,.""`.•�^(0��/ dam y. t ; `.FO DEPARTMENT USE ONLY Application Accepted bya,4�n!/JDate p r� Area f I 1 5 - h . D j Pit or Grout Inspection by Date ".Final Inspection by t 1. Date �-U-0e ! Additional Comments: ❑'Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823=7104 ^ `'❑ Tracy 835-63$5 Applicant - Return all copies to: Environmental Health Permit/Services160.-E:,Hazelton Ave., P.O. Box 2009, StFEE k., CA 95201 j t Ag INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY bA PERMI7'NO, �O s + EH-13-24(REV:Id A 51 .�-,,. .ate _ _ r..,•-..-�•,..,..-+,..�.�.�.-",..."� .... ..•....w.... _ � h EH 14-29 --- --�'^�..r+.�..-....�-. - •�icc,7 F-c-