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" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ~� 1601 E. HAZEL TON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED {Complete in Triplicate) r /r4 4; ✓ r'0 6 k 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. Job Address =T 7 c� _ City Lot Size .5,10 PM Owner's Name Address Phone '7 M J Q Contractor Address License No. Phone_ _TYPE OF W L/PUMP: NEW WELL ❑ WELL REPLACEMENT Q 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 yDia. of Well Excavation Dia. of Well Casing w� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (zV i`l Public ❑ Other H Delta Depth of Grout Seal Type of Grout W I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 nf� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION l 1 DESTRUCTIO [No septic system permitted if public sewer is f vailable 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 t LEACHING LINE ❑ :No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ll Depth Size Number SUMPS 0 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 c unty ordinances, state laws, and 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 subject to workman's compensation laws of California."Contractors 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 erripfoy-persons subject to workman's compensa- tion laws of California." The applicant s all fora .r quired rns Vis. C plete-drawing on reverse side. a �.Signed X Title: Date: �FORPARTMENT USE ONLY - Application Accepted by �x ') Date �!/ Area D Pit orGrout inspection Date Final Inspection by—_ Date Additional Commen 2 n " _k"ie_ tl-KS, f ❑ Stk 466-6781, ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835-63$6 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 044- FEE INFO AMOUNT DUE AMOUNT REMITTED K CXV RECEIVED BY DATE PERMIT•NO, EH 1 -24]REV. 4 /a 5l C Ilia