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(-� 4 APPLICATION FOR PERMIT r�Lrr1 v SAN JOAQUIN LOCAL HEALTH DISTRICT i .rS _ �c� 5 1601 E. HAZEL T ON AVE., STOCKTON, CA } Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED j £ (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 with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for w I/pump and thee+Rules and Regulations of the San Joaquin Local ,Hsealth District. lilll Job Address .Wrk � City v Lot Size PM 1` y Owner's Name n V1 Address. !i)! ��1 � �� Phone PSL l \` Contracto6T4, Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �J PUMP-INSTALLATION_❑.,- .,....._,-.._._-SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK '�— SEWER LINES `~ DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS df , ❑ kndustrial &15-pen Bottom ❑ Manteca Dia. of Well Excavation z Dia. of Well Casing ❑ stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �Q 1172. Specifications + 1 fblic ❑ Other 11 Delta Depth of Grout Seal e5V- Type of Grout 9 Sa _. I-1 Irligati 70.Approx. Depth 1 1 Eastern Surface Seal Installed by(-K 1'12dit n _ e rr ork Done ❑ Type of Pump H.P. State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') �` ! TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) d Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depthof 3 feet: ,Water table depth SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line _ I LEACHING LINE, ❑ No. & Length of lines Total length/size FILTER BED"'r! ❑ Distance to nearest: Well Foundation Property Line ". SEEPAGE PITS I I Depth Size Number " SUMPS ❑ Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ 11 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. 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 work man's,compensa- tion laws of California." The applicantmust I for all re ired i pections. Complete drawing on reverse /side. Signed X ZVo A Title: Date: _ • �0 DR EPARTMENT USE ONLY Application Accepted by v�`'�'"� Date f t7 l Area T Pit or Grout Inspection by r ata Q Final Inspection by � Date F . Additional Comments: ❑ Stk 466-6781 ❑ 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.r CA 95201 f INFFEE OUNT DUE AMOUNT REMITTED CK 0 ASH i RECEIVED BY DATE PERMIT NO. +.EH13-241REV.r/x51 � �� C1OM1 1_7 EH 1426 I ��\ `P