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APPLICATION FOR PERMIT�47 _� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA L , Teldphane 1209) 466-6781 }�,t PERMIT EXPIRES 1 YEAR FROM DATE _Erxv Irl (Complete in Triplicate) Application is heieby 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 compiiance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump Ind the Rules and Regulations of the San Joaquin Local Health District. 69 r, t PM Job Address City -/r�Eot`Size y� c Jr f �{ : Address O �r ' 4� f f 4 G �J Owner's �ldfiiia r ! J 1 Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT El DESTRUCTION ❑ r • PUMP INSTALLATION ❑ SYSTEM REkR ❑ OTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. Pno3 . LINE FOUNDATION AGRICULTURE WELL OTHER WEL — ".r PITS/SUMPS INTENDED U TYPE OF WELL PROBLEM AREA CONSTRUCTION SPWFICOT10f3S ❑ Industrial ❑ Open i Manteca Dia. of Well wo anon Dia. i f Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy asing Specifications I') Public ❑ Other ❑ Del Depth of Grout ea Type of Grout I # Irrigation _..Ap ro I Eastern Surface Seal Installed by Repair Work Done a of Pump H.P. State Work Done r Well Destruction 1-1Well Diameter Seating Material (top 501 4 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer i5 available within 200 feet.) I Installation Will serve: Residence Commercial_ Other .\ Y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth " t� SEPTIC TANK O Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well -Foundation Ptoperty Line 1 r I •�. i S LEACHING LINE ❑ No. & Length of lines i t Total lengthlsize N FILTER BED ❑ Distance to nearest: W611 _._ Foundation Property Line i f SEEPAGE PITS 11 Depth Si}e Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI I hereby ertify that 1 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 shalt 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 certified the following: "I certify.that in the parfdrnience of the work for which this permit is issued, I shall employ persons subject to workma> compensa- tion laws of Califotnia." ` 1 Theapplican9mil for all required461; to drawing on reverse side. `- Signed X J '' Title; Data: FOR DEPARTMENT USE ONLY � 4� Application Accepted by Date [ Area Pit or Grout Inspectio y Date Final Inspection by CPeAdditional Comments � I ❑ Stk 466-67$1 ❑ Lodi 369-3621 EI Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.D. Box 2009, S1k., CA 95201 M FEE AMOUNT AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH EH 1324IREV.1iµ51 y -H 14-2a f