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i APPLICATIOWFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.; STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate} 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 Vl itfi 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.,'= ''� _ II - ._ Job Address " 4 Y' City Lot Size PM Owner's Name Address '` Phone Contractor's Name a'-`Cicen'se No. Phone TYPE OF WELL/PUMP: ! NEW WELL ❑ WELL REPLACEMENT ID DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION # AGRICULTURE WELL OTHER WELL PITS/SUMPS r n IF' INTENDED USE ": TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V! ❑ Industrial -i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation---- �--- �+tDiaa=of Well Casing ` ❑ Domestic/Private ❑ Gavel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Deptlr of Grout Seal r Type of Grout a 11 Irrigation --Approx. Depth 11 Eastern Surface Seal Installed by I� o - Repair Work Done LlType"of Pump H.P. State Work Dona 'Well Destruction ElWell Diameter Sealing MateriaYl (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence-A Commercial Other i Number of living units: Number of bedrooms Character of soil to a depth of�3 feet: t.- * Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0Method of Disposal Distance to nearest: li ell Foundation t Property Line LEACHING LINE ❑ No. & Length of lines t Total length/size .i FILTER BED ❑ Dikance to nearest: ',Well Foundation Property Line 1 / SEEPAGE PITS ❑ Depth f5ize Number SUMPS Distance to nearest: Well IIAAA&enundation Property Line _ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dont'"in`accordance with San'Joaquin county ordinances, stafe.laws, and rules and regulations of the San MJoaquin 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 subject to workman's compensatiom 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." �I t.rw� r f, The applicant myg ca or all req ' spections. Complete drawing on 'averse side. Signed X TitEe: Date: } . FOR DEPARTMENT USE ONLY Application Accepted by _C-/ _,� _ • Date_5- aA_RA Area a T LPit or Grout Inspection by ,�,."c � �1 Date 5-3a-W A Final Inspection by_e�e.�..�. L?..,�4a.�Q�w Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi r 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to::Environmental Health Permit/Services 1601 E. Hazelton Aver P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIYNO. +EH EH 13-24 3-28IREV.101831 it LYVLG�