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A-,.,y ;,I.y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "" t 1601 E. HAZEL T ON AVE., STOCKTON, CA k� J 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 Ai'Aid0-.1T6israpplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations,If the San Joaquin Local Health 9District.. Job Address 1 � [`�Q/ W• M City Lot Size PM Owner's Name Address ^� c/1 Phone Contractor Address�?F�/G 6A44 ar.� l�nse No. QPhones-,6�t j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout --- I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done )C Type of Pump H.P. I� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 p� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other -- �` Number of living units: Number of bedrooms -Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 0 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 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 Di$trict. 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 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 applicant must tali for qJ11 required ins trio late drawing on r rse side. Signed X Title: ��Ess"� Date: F. DEPARTMENT USE ONLY �f J Application Accepted by Date , Area /"` Pit or Grout Inspection by Date Final Inspection by Date 9 15� Additional Comments: El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 5 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVE)BY DATE PERMIT'NO. INFO CASH ♦ EH 13-24(REV.i mt) EH 14-26 LI