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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 4 �► �t� Telephone (209) 466-6781 ¢E�' PERMIT EXPIRES 'I YEAR FROM .DATE ISSUED (Complete in Triplicate) J�L (a�p`� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descr � N �tT'�n�is made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rules and R@g�'F�� an Joaquin Local t Job City City Lot Size PM Owner's Name �G `L I o5 Oro Phone l� Contractor ddress No. Phone TYPE OF WELL'IPUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA="CONSTRUCTION-.SPECIFICATIONS- Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f 1-1 Public ❑ Other ' 17 Delta Depth of Grout Seal _ Type of Grout. I I Irrigation -Appro4x Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of PurnpH,P. State Work Done_ Well Destruction WI Well Diameter 711 Sealing Material (top514�I Depth AA+Ebk, Filler Material (Below�5 91 Q" d� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I iNo septic systam permitted if public sewer is available within 200 feet.) Installation will serve: Residence I Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ T } i ype/Mfg Capacity Na. Compartments PKG. TREATMENT PLT, ❑ } Method of Disposal distance to nearest: Well Foundation ____ Property-Line - ' I LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance'to'nearest: Well Foundation Property Line -4 SEEPAGE PITS I I Depth t l Size _ Number ' k1 ' SUMPS ❑ Distance to nearest: Well Foundation Property Line .., ...DISPOSAL PONDS ._ O-.._- — �:— ..-_. _ 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 D+iltrict. , Home owner or licensed agent's signature certifies the following: "I certify tl'at 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 i 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 Calif rnia." The applice st call for all req uir spections. Co let. drawing o .1-e si ,7 Signed X ` Title: 7 � Date: 2�6 0 OR DEPA EN USE ONLY � Application Accepted by Date 1/ �^7 , AreatlT Pit or Grout Inspection by Date Final Inspection Date Additional Comments: I ❑ Stk 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.Q, Box 2009, Stk., CA 95201 11 FEE INFO AMOUNT DUE AMOUNT REMITTED) A RECEIVED BY /� DATE (� PERMIT'No. +.EH 13-24 1REV.r/a sf 3\ 60 0;/ �J 60 EH 14-2111 r.