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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 4 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR .FROM DATE ISSUED f (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. IR&(P/Q _,/7/UT�f Job Address Q City Lot Size PM J,LC a( I- QQ NneY�� a �T VA Phone Owner's Name Address 4S�T N - " Contractor e_• Ofi�^+�'y Address a(T z� tri License No.Sclf� Phone TYPE OF WELL/PUMP: NEW WELL IV WELL REPLACEMENT ❑ -DESTRUCTION ❑ PUMP INSTALLATION fps SYS7EM_M3EPAIR ❑ — OTHER ❑ t r DISTANCE TO NEAREST: SEPTIC TANK --�J� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private -"'L] Gravel Pack ❑ Tracy 0. Type of Casing - —Specifications_4 4 i f Public ❑ Other ❑ Delta S Depth of Grout Seal Type of Grout _. r I i Irrigation Approx. Depth I I Eastern i Surface Seal Installed by _ f r f A Repair Work Done ❑ Type of Pump H.P. State Work Done_ r Well Destruction , ❑ Well Diameter Sealing Material (top 50') r + t Depth Filler:Material i8elow 50') w f Q TYPE OF SEPTIC WORK: NEW INSTALLATION rT REPAIR-/ADDITION i.l DESTRUCTION i I (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence Commercial_ Otht r if Number of living units: Number of bedrooms Character oll`soil to a dep of 3 feet: Water table depth } SEPTIC TANK^ Type/Mfg Capacity�o�.. 0` No. Compartments f PKG. TREATMENT PLT. ❑ ,�• .� P : Method of Disposal Distance to nearest: Well Foundation` Property Line , LEACHING LINE No. & Length of lines .tea P-77 ;Total length/size +f b FILTER BED ❑ Distance'to nearest: Well F*--r-Foundation—R*1 Property Line SEEPAGE PITS i I Depth 1 Size 4 Number SUMPS ❑ Atance to nearest: Well Foundation + Pr perty Line + DISPOSAL PONDS ❑ I hereby certify that t 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. 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 shalt 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 worICfor which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." +"'� r The app7iit all required inspections. Complete d7al on reverse side. '" r +[* Signed -1Title: ��(1�� iY[ G✓O Date: ` i - 3 FOR DEPARTMENT USE ONLY Application Accepted by Data Area - Pit or Grout Inspection b Date Final Inspection by - Date Additional Comments: f It Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 ❑ Tracy B3 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., .P,O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. +xfHt3-24{REV.riK51 lD EH 14-26 h