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q '• '{;.z APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 Ne'7 �1A1e_ fl�t1 Y!1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k i..Y_ 01..-b per hcit (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. " �.�� l7 oy�''' �jj 4 9 �) / f - 'yam e Job Address 1^Orf ;2. lf� '- City -25h/ not Size 6� 3a _PM / / 1 LL Owner`s Name +°�+1��'�Ofdress �1 c�*J a Y`d ! -hiL' hone Y6 y r 3 yyri=a Contractor e.! Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ x ` PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ Vf/� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE jJ FOUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS INTENDED USE `TYPE OF WELL` PROBLEM AREA CONSTRUCTION SPE ATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T asing Specifications ❑ Public © Other ❑ Delta Depth of Grout Seal Type of Grout 4 ❑ Irrigation --Approx. Depth astern Surface Seat Installed by -- n Repair Work Done ❑ Type_ p H.P. State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑+ AEPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is s available 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 1❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLTt ❑�-;� ';`, ; Method of Disposal • •' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PETS ❑ Depth Size Number SUMPS ❑ 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 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 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 for all required in ctions. Complete drawing on reverse side. �-d 'y� 7 Signed Title: Date: • A � t R DEPARTMENT USE ONLY 4 i Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date �l Additional Comments: ww ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ AAeca 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 FEE AMOUNT DUE AMOUNT REMITTED CK# INFO CASH RECEIVED BY . DATE PERMIT NO. a EH 13-24 iREV.t i w s1 J�,LEH -28 CrIls Zs Q f