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i �.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT `i 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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. ; Job AddressIZ9City.57"Zk< Lot Size �� PM 1 1�1 Address 5 'Z P�pf a Phone y � Owner's Name n � � t.- - Contractor-�i.c�€— " Address _ License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' Specifications ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing — [7 Public Cl Other R Delta Depth of Grout Seal Type.of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Dane ❑ Type of Pump H,P. State Work Done n Well Destruction ❑ Well Diameter Sealing Material Itop 50') .r- Depth I Filler Material (Below-50') -- TYPE OF SEPTIC WORK:' NEW INSTALLATION 1.1 REPAIR/ADOITION I I DESTRUCTION XiNo septic system permitted it public sewer is • } ailable 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 PKG. TREATMENT PLT. ❑ Method of Disposal iDistance4.to nearest: Well Foundation Property Line ' I }� I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance rto nearest: Well Foundation Property Line SEEPAGE PITS 1 I I Depth Size Number SUMPS Ll Distancelto nearest:. Well Foundation- Property Line DISPOSAL PONDS ED 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 I rules and regulations of the San Joaquin Local Health Di?;trict. 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 1 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." r ;3 The applicant must call for all required inspections. Complete drawing on reverse side. J Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ea f Pit or Grout Inspection by y a to Final Inspection by e J Additional Comments: ❑ Stk 466-66781 ❑ Lodi 3669-3621 ❑ Manteca 823-7104 ❑ Tracy 835-MS Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMLTTED CK RECEIVED BY OATS PERMIT N0. INFO CASH ten} �7� /�7_ 7 +.EH t3-24 INEV. i x 51 `J � �— Fks _ U vw f EH 14.26