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f f APPLICATION FOR PERMIT e SAN JOAQUIN LOCAL-:HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 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 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 City Lot Size PM_ ' Owner's Name Address Phone +t ~ rf Contractor ss icense No. Phone �� TYPE OF WELL/PUMP: NEW WELL ❑ WELLI REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER'❑, `�+ l DISTANCE TO NEAREST,: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS;y f ? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; r # ❑ Industrial ❑ O � pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing M ❑ Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing 1 ! /Pi9 Specifications ❑ Public ❑ Other ❑ Delta ---� -Depth of Grout-Seal—----- Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done. F ' Well Destruction ❑ Wel! Diameter t Sealing Material (top 501 Depth Filler Material (Below r TYPE OF SEPTIC WORK: NEW INSTALL, ION ❑ REPAIR/ADDITION Wr ESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l € 1 Installation will serve: -Re)sid,encs Commercial'E_,_Other Number of living units: L Number of bedr oms� Character of soil to a depth of 3 feet: Water table depth \ SEPTIC TANK ❑ Type/Mfg t `Capacity No. Compartments PKG. TREATMENT;PLT.;❑ -�^- ° Method of Ql TI Distance to nearest: Well• -Foundation Property Line LEACHING LINE [ No.',& Length of'lines " i Total length/size` FILTER BED ❑ Distance to nearest: Well 1 00 Foundation .: 'Property-Line SEEPAGE PITS 1` Depth._16z ' Ammher ifj UMPS ❑' ,Distance to nearest: Well # Foundation Property Line__. ! DISPOSAL PONDS ❑ 3. I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 'i 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 workman's compensa- tion laws of California." The applicant must cila for all requ spections. Co, to drawingon side. Signed Title:�� Date: VA9 !2, FOR DEPARTMENT USE ONLY Application Accepted by Date Pis or Grout Inspection by Date ^Final Inspection by Date �� ss j _// s Additional Comments: - 5' S ld C ` V� , 24 ❑ Stk 466-6761 ❑ Lodi 3&36521 ❑ Manteca 823 104 ❑ Tracy 835.4�> - Applicant- Return all n copies to: Environmental Health Permit/Services 1 p }FEE 1 /Se loss 1fi01 E. Hazelton Ave., P.Q. Box 2009, Stk., C 01 INFO AMOUNT DUE' AMOUNT(REMITTED CASH RE�CnvEIIVED BY DATE PERMIT[N0. __T + EH 13-24 EH 14-28 rREV,i i a 5) _70. .00 h I*✓ �� T�