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IrAPPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA2�-- I Telephone (249) 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 con -stru o II 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. 14 ,Z 7 ) z F, FY i ri. o nT City Seo t A 141% Lot Size"" ""`" PM Job Address • Owners Name Sia c A io n /10. Tr k Address A Ck Phone �O r Contractor � �q A e � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ a 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 C3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing — Specifications ❑ Public ❑ Other ( ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Easter Surface Seal Installedjby Repair Work Done ❑ Type of Pump H.P. State Work Done �+ Well Destruction 13 Well Diameter+ . Sealing Material Itop NY) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION INo septic system=permitted it public sewer is ( available within 200 feet.) Installation will serve: Residence_ ^! Commercial Other Number of living units: Number of bedrooms— Character edrooms Character of sail to a depth of 3 feet: _._W...., ..._,_._,....... .-..._ _ Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q Method of Disposal, Distance to+ nearest 'Well", - Foundation Property Lme" + Total len h/size LEACHING'LINE ] No. &Lengtaf lines, length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 0 Depth Size Number SUMPS '❑ Distance t".Y nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ;I 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§ignatuie certifies the following: "I certify that in the performance of the work for which this penrmit 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 employ persons subject to workman's compensa- tion laws of California." - The applicant must call for all required inspections. Complete drawing on reverse side. Signeda.c.� c..�cwz �/. �. Title: Date: f>1 /p6 FOR DEPARTME USE ONLY Application Accepted by ' _ ` Date Area Pk or Grout Inspection by Date anal Inspection by dim Date itional Comments: `,OkS ' tk 466-6781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 83548385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTEDCASki RECEIVED BY DATE PERMIT"NO. INFO +EH 13-241REV.1 8W 3 A0 EH 14-26