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j APPLICATI�°�, �..,�, N FOR PERMIT SAN JOAQUIN LOAL HEALTH DISTRICT [� 1601 E. HAZEL T ON AVE.,,STOCKTON, CA 1 y Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : AComplete 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.,,' -- t �ce . - _ - : , - Job Address City O w Lot Size ". PM Phone Owner's Name � Address 33 Contractor Addressry ,5 -- e- License Nr3 Phone a TYPE OF WELL/PUMP: a= NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR CY OTHER ❑ t DISTANCE TO NEAREST:,SEP71C TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El-Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing -�' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T` j �� Type of Grout ; (ilrrigation _--Approx.:Wth EJ Eastern Surface-Seal Installed by t nn Repair Work Done �R Type of Pump -ltk I_--- H.P. &0 State WoWDone� Well Destruction ❑ Well Diameters Sealing Material Itop 501 Depth ! Filler Material {Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.)' p Installation will serve: Residence Commercial— Other. I Number of living units: Number of bedrooms l I Character of soil to a depth of 3 feet..l !_Water table depth n l SEPTIC TANK ❑ Type/Mfg 1 .Capacity I J No. Compartments PKG. TREATMENT PLT. El " Method of Disposal i Distance to nearest: Well Foundation } Property Line s LEACHING LINE 11 No. & Length of lines I' Tota! length/size FILTER BED 11Distance to nearest: Well Foundation t Property Line 4 [� SEEPAGE PITS ❑ Depth +'�` Size `#hfumtier SUMPS ❑ Distance to nearest: Well Foundation Property Line t.�... L � 1. 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. - 'r, Home owner or licensed ageht'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 2s to, ecome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting sigriature 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 app must II for all require i ctio Comp drawing on r7 side. Signed Title: Date: �> FOR A � ,T USE ONLY Application Accepted by Date �� Area Pit or Grout Inspection by Date Final Inspection by Date �`21 Additional Comments: - + ;J - ❑ Stk 466-6-81 _-� X13 Lodi 369-3621 ❑ Manteca 823-7104 4 El Tra* 83576385 - Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P-O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH13-24(REV.I R5) EH 14-28 _