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,APPLICATION FOR PERMIT V 4,SAR SAN JOAQUIN LOCAL HEALTH DISTRICT SAN JOp.QUIN LOCAL 1601 E HAZELTON AVE., STOCKTON, CA ,,Fj,-TH ®ISTRiCT Telephone 12091 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 applicationis 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. I 4`, ! ,1 , Y ,.,� r-..� .. Job Address ZZ r �/ fJ' r _ City- t Size PM �� v Owner's Name �ddress � �r 1 Phone //3 Contractor's Name >/Z License No. `L Phone —546 f6z,r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT;_El- . DESTRUCTION 173PUMP INSTALLATION Ll SYSTEM SYSTEM REPAIR t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' ❑___.//Domestic/Private El Gravel Pack ❑ Tracy Type of Casing ~Specifications -' 91 ublic ❑ Other ❑ Delta Depth of Grout Seal of Grout ❑ Irrigation ---Approx. De_pty+❑ aastern Surf a Seal Installed by .� Repair Work Done L� Type of Pump N/ H.P. e 3� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is available within-200 feet.) Installation will serve: Residence_ Commercial_ Other r O Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No..Compartments PKG. TREATMENT PLT. C7 Method lof Disposal Q Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line` t SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E 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 a San Joaquin Local Health District. Home owner or I- nsed age '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 p on in such ma er as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the (lowing:"I ce that in the pe ormance work f which this permit is issued,I shall employ persons subject to workman's compensa- tion laws Califon- _ _ - The appli ant all requir mplete d wing on reverp side. Signed Title: Date: O FOR DEPARTMENT USE ONLY Application Accepted by Date l?�Area Pit or Grout Inspection Date Final Inspection Date Additional Comments: ' 'I ❑ Stk 466-6761 0 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CAST{ RECEIVED BY `DATE PERMIT`NO. + EH 13-24(REV.10183) J-1 EH 14-25 Y t