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# w. APPLICATION FOR PERMIT SAN JOAQUIN IOCAL HEALTH DISTRICT E� h! 1601 E. HAZELTON AVE,, STOCKTON CA Telephone (209) 466-6781Sr b PERMIT EXPIRES 7 YEAR FROM. DATE ISSUED ' (Complete in Triplicate) `. `ENVIROMkNTAL HEALTH I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workMERV"plication is ` made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1861 for well/pump and the Rules an egulations of the San Joaquin Local Health District.,, Job Address City Lot Size PM Owner's Name OQ L,C IV z y14Address 1 Phone 5 Contractor's Name License No. A Phone (1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ vim} PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing i U/Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications l ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Al. 1-1Irrigation ---4pprox!Depth ElEastern Surface Seal Installed by 'i Repair Work Done ❑ Type of Pump" :9 4M 07 H.P. State Work Done No VkP i Well Destruction ❑ Well Diameter Sealing Material (top 50') r' Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic 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 i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 f LEACHING LINE ❑ No. & Length of lines Total length/size. FILTER BED ❑ Distance to nearest: Well Foundation Property Line i F SEEPAGE PITS ❑ Depth Size 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, and rules and regulations of the San Joaquin Local Health District. e 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." f - The applica st call for all requireA inspections. Complete drawing on reverse side. s elf Signed 27;2- + Title: `// Oate. OR.DEPARTMENT USE ONLY ✓ . �1 Application Accepted by .• Date rea Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: _ ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca M-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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE�-yam PERMIT`NO. + EH 1324(REV.101831 EH 1426