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:_.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. .HAZEL i ON'AVE., STOCKTON, CA Telephone (269) 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/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. i Job Address Cite Size PM Owner's Name 5� . F1 Phohe 4 'ST r_b,F_ Contractor Ln w. Address D �7 .!s C q Z 7 License No. Phone .TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT El DESTRUCTION 11i PUMP INSTALLATION iY 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 u ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications w Piilblic fl Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irng ation / .Approx. Depth l I stern S ri� Seal Installed b Repair Work Done N'- Type of Pump H.P. �� State Work Done Vqr�rS4JO Well Destruction ❑ Well Diameter Sealing Material (top 50') / Depth Filler Material (Below 501 , n TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I Wo septic system permitted if public sewer is (V1] available within 200 feet.) Installation will serve: Residence— CommerciI_____ Other Number of living units: Number of bedroom Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LJTypelMfg Capacity 7' No. Compartments `f PKG. TREATMENT PLT. ❑ — LL Y Method of Disposal Distance to nearest: WellFoundation j �k f Property Line; y LEACHING LINE ❑ No. & Length of lines F Total length/size FILTER BED LI Distance to nearest: ndation k'.'24 Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 regulatio a San Joaquin Local Health Di§trict. Home owner icensed age 's signature certifies the following: "i certify that in the performance of the work for which this permit-is issued, I shall not empic y any arson in such ma ner as to beco subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Certifies t followin "I terti that in the rmance work for which this per is issued, I shall employ persons subject to workman's compensa- tion law of Calif. _ _ .' The ap icant m s all req rawing on ve ide. Signed Title: "� r -date: C�r ,� .– 4OR D f1MJF ENT USE ONLY 2 i Application Accepted by Date ✓ Area 2 t Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stik 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 ,n IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. \(� +.EH 1124 1RIEV. EH 14-2e