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APPLICATION FOR PERMIT r ry � JT'a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Ll� Telephone (209) 466-6781 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 Jor9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. /" ? S� Com.# O f1 Jab Address City Lot Size 00 to PM { p3 S !�— Phone C! Owner's Name �-��C��-J-C 10� - Address Contractor Address License No. Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION F1SYSTEM REPAIR 13OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed byIN - Repair Work Done ❑ Type of Pump+ -� " WP, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material Welow 501 ! TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted.if public sewer is vailable 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 ❑ ; Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal k Distance to nearest: Well Foundation Property Line I r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ VVI be done.in.accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work 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 r employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following. "I certify that in the performance of the work for which this permit is issued, i shalt employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X��a 1'pl ,� !'1�lt '- Title: Date: S S FOR DEPARTMENT USE ONLY '�— Application Accepted b Dates Area Pit or Grout Inspection by Dat Final Inspection by Date KL�e 4-10ZA 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 FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT N0. INFO F + EH 13-24 1REV. EN 14.26