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L APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA l� Telephone (209) 465-6781 PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED _ l' :3 .{Complete'in Triplicate} � f r 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 corrlpliance 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.Y ,S,;i3iT s Job Address City _ Lot Size PM Owner s Name " — YAddress ,, sZ w+° Phone Contractor's Na License No. Phone Pw TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD._._ PROP. LINE T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t f- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing!_ I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ; ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___4pprox_Depth... D.Eastern_. ,M_Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump _ H.P. State Work Done Well Destruction ❑ Well Diameter i •-.Sealing Material (top 501 Depth _ Aller 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 I Other Number of living units: Number droo s r Character of soil to a depth"of 3-feet:--- -�- - Water table depth _ SEPTIC TANK Type/Mfg - CapacityAl, 00,04 No. Compartments PKG. TREATMENT PLT.❑ t t / Method of Disposal ,� a !�+- r Distance to nearest: Well Foundation.._._L Property Line LEACHING LINE ,et'No&,Length of lines "p"' "/# Total length/size FILTER BED 1-1Distance to°nearest:�' Well_ Foundation`® - Property Line s �. SEEPAGE PITS pa ,Depth 17 1 Size Number nearest:`# i Pro ' � SUMPS -` 'f"- ❑ Distance to `'Well _ Foundation Property Line_.. r 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.- Home istrict.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 r 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." .The applicant must call f�Mired'lnsp_eetion �Complete drawing on reverse side. „ _..y.... s Signed Title: Date yt , - � y-- FOR DEPARTMENT USE ONLY j Application Accepted by 1 -1Date (% _ Area.' for Grout Inspection by Date-z = '�JFinal Inspection by ate. i Additional Comments: + — ❑ 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.O. Box 2009, Stk., CA 95201 i FEE,-- AMOUNT DUE AMOUNT REMITTED CC.4SH RECEIVED BY DATE PERMW NO. INFO .4 = rt- .. .�, 1 +EH 13-24(RE1l.10183) t l�.7` , _ �Q/ S' 5 �U EH 14-28 r a