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I - -"r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL.TON AVE., STOCKTON, CA E Telephone (209) 466-6781 i PERMIT EXPIRES i 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.j his 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. I Job Address Of City 4 ,0 0 Lot Size. lo / gyp Owner's Name Add I res Phone" i i0o,d Contractor's Namecense No. 4- / ' ._-. Phone 2. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT © DESTRUCTION ❑ P6iMP'INSTALLATION'"29 SYSTEM'REPAIR'"❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _SEWER,LINES.. ��-DISPOSAL FLD. PROP. LIME r� FOUNDATION AGRICULTURE WELL `"µ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL j PROBLEM-AREA CONSTRUCTION SPECIFICATIONS -� ❑ Industrial pen Bottom' ❑ Manteca Dia. of Well Excavatio r Dia. of Well Casing [4Dlrme`stic/Private L] Grave! Pack ©Tracy Type of Casing ' Z(, Specifications �.41 ❑ Public El'Other i t ❑ Det Delta Depth of Grout Seal I _y�'�, 7� 7 pe of Grout ❑ Irrigation ---Approx. Depth 10 stern S rface Seal Installed by Repair Work Done -❑ Type of Pum H.P. _ State Work Done Well Destruction` ❑ Well Diameter t Sealing Material (top 501 Depth Filler Material{Below 50') I TYPE OF SEPTIC"WOR"K: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION IJ INo septic system permitted if public sewer is O ` available within 200 feet.) Installation win serve: Residence_ Commercial_ Other OQ Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg I. CapacityNo. Compartments. " PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest!: Well Foundation Property Line f LEACHING LINE ❑ No. & Lengthof lines Total length/size FILTER BED ❑ Distance to nearest': Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS - ❑ I 1 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:"1 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 The applican7mu call for all required inspections. m late drawing on reverse side. � t Signed X Title: Date: A ^ A � ; FOR DEPARTMENT USE ONLY Application Accepted by Date s Arear} Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 r ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 95201 CK 0 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY f DATE PERMIT'N0.' . + EH 1324(REV.1018:11 ( h.�/ V74 EH 1428 S Q c7 J�, E + v � I•I I Ir f