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i } APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p AY M ENT 1601 E. HAZEL—1 ON AVE., STOCKTON, CA R14:91"t) z Telephone 42091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP i (Complete in Triplicate) ' ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thewgfl �This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R es an egulations of the San Joaquin Local Health District. a s >4c-v 0 Job Address 4491.f If Lot Size PM Owner's Nam Addressa Phone Contractor!&&� Address//771'02 License No.Y� �Phone "� C TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ il PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER v) 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 El Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing � i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout . ❑ Irrigation --Approx. D pth ❑ Eastern & Surface Seal Installed by Repair Work Done Type of Pump H.P. StateYork Done E i Well Destruction ❑ Well Diameter Sealing Material itop 501 Depth Filler Material (Below 50'); .TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A-DDITfON I❑•DESTRUCTION ❑-(No seiitic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water.table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line1 'e LEACHING LINE ❑ No. & Length of lines Total length/size— FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS - ❑ Depth ~` Site.{' "' r �. Number SUMPS ❑ Distance to nearest: Well Foundation ?' Property Line DISPOSAL PONDS ❑ 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, an 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 call f i required inspections. Complete drawing on�-verseseside.Signed XTitle: SE�f Date: FOR DEPARTMENT USE ONLY 1 Application Accepted by _ Date ! b Area 97, I Pit or Grout inspection by Date Final Inspection by h DateL +� 3L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 # RECEIVED BY DATE PERMIT'NO. INFO / /,CMH + EH13-24iREV.S/851 � y _,1 Q') EH 14-26 ./ !� 7