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i " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �U� 11 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209)'465-67$1 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. Job Address "v City Lot Size PM Owner's Nam Address Phone r 3 Contractor's Name QU114 License No. '¢'� L�' Phone egr4 TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION d PUMPI INSTALLATION ❑r.� SYSTEM REPAIR 13 OTHER 11DISTANCE TO NEAREST: SEPTIC TANK 1�1 SEWEA LINES DISPOSAL FLDPROP. LINE _ } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing G P,Tomestic/Private �avel Pack ❑ Tracy Type of Casing f LIC– Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 45 Vd H.P. State Work Done Well Destructioniyij[ Well Diameter tr Sealing Material (top 501 t Deptlii �� 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: Residece_ Commercial_ Other y Number of living units: iM 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. ❑ I� "" Method of Disposal Distance to Barest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I ' SEEPAGE PITS —❑ 'Depth- Size Number 1. a SUMPS "❑ Distance.to,riearest: Well FoundationProperty Line � p DISPOSAL-PONDS-r fL7-" rr k l 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. 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 dny person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifes.the following: "I certify thit;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 r all fired inspedtions. Complete drawing on reverse side. 1 Title: Date: + Signed - .I s,f FOR DEPARTMENT USE ONLY _. r "Application Accepted by Date '7--7>— Area . —�7' – Pit or Grout Inspection by ' ate Final Inspection by Date Additional Comments: � ❑ Stk 466-6781 CJ Lodi! 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 k Applicant- Return all copies t II Environmental 149aftlh Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ail FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT"NO. INFO + EH,3-24 IREV.10183) A 4110 I" l EH 14-28 -