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r !9 APPLICATION FOR PERMIT ,i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i 4 (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 Dis nct. a PMY City Lot size Job Address 0 . Address '_ — Phone Owner Is Name ;"}- N F ress - r'L'icense-No`— -P hone— � O• 7 T,—,tractor T TYPE OF WELL/PUMP: 'I NEW WELL ❑ WELL REPLACEMENT DESTRUCTION LI t "PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Ftp, PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I TYPE-OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u❑ open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial Pe{ : ❑ Domestic/Private +❑ Gravel Pack' ❑ Tracy Type of Casing ' Specifications i �. Type of Grout ❑ Public iq Other " ❑ Delta Depth of Grout Seat - aJ A rox. Depth ❑ Eastern Surface Seal Installed by 13 Irrigation PP j Repair Work Done ❑ Type of Pump H.P. State Work-Done I{J t Well Destruction ❑ Well Diameter u Sealing Material (top 50') ' i Depth Filler Material {Below 50') ` 4 TYPE OF SEPTIC-WORK: NEW INSTALLATION AEP R/ADDITION ❑ D STRU ION, a�ailabPe�withm 200 feet.) if public sewer is r . r Installation will-sere: Residence Commercial_ Other a� Number of living units Number.:of bedrooms , Water table depth Character of soil to a depth of 3 feet: .+s s SEPTIC TANK ❑ Type/Mfg tCapacity No. Compartments Method of PKG. TREATMENT PLT. ❑ ` " $ l,josal I Distance to nearest: Well Foundation -- Property Line t : EACH I N G INE ❑ No. & Length of lines. Total length/size % FILTER BED ❑ Distance to nearest: Well� Foundation 2 Property Line i < tt. FSize I Number ` EEPAGE PIT E03Depth Y i SUMPS El Distance to nearest: Well n Foundation }Property Line i DISPOSAL PONDS ❑ d that the work will be done in accordance with San Joaquin county ordinances, stat I hereby certify that I have prepared this application ane 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of�Californla."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 applican ust II for all r inspections. CompI to drawing on/,lr/$.�@if�je side. kv Signed Title: Date: L FOR DEPARTMENT USE ONLY # Application Accepted by r Date a� ( Area ! Pit or Grout inspection by Dae Final Inspecti n by Date Additional Comments: e # ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 85 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 i t AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �:DA�TE PERMIT NO. FEE � INFO it 1_L1 �1`N + EHf3241REV.7/a51 �� EH 1428 Y I�