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APPLICATION FOR PERMIT s` SAN JOAQUIN LOCAL HEALTH DISTRICT IE 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 c PERMIT EXPIRES 1 YEAR',FROM DATE ISSUED !I (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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address r `--' `� City�tLot Size PM Owner's Name a]j Address Phone j. Ctractor Address d C License No. � one ��P- onTYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `4L: ;i PUMP INSTALLATION_ T SYSTEM REPAIR ❑ OTHER 11 ; ff DISTANCE TD NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS !i ❑ Industrial ❑ Open Bottom ❑ Manteca I Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications p ❑ Public i C1 Other ❑ Delta Depth of Grout Seat Type of Grouti. ❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by ! �.-.T-�_ _._.. ..._..� ._Win.._I ,. Repair Work Done E) Type of Pump H.P. State Work Done Well Destructibn ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted ifrpubfic sewer is available within 200 feet.) Installation.- ill serve: Residence commercial Other Number ofliving units:_L_ Number of bedrooms Character o soil to a depth of 3 feet: _ _ Water table depth SEPTIC TAN l] r Type/Mfg Capacity, No. Compartments PKG. TREATMENT PLT. ❑ } i Method of Disposal :! -Distance to nearest: Well t Foundation r Property Line i LEACHING LINEiYil�o. & Length of lines ' + /Tootel length/size FILTER BED ❑ Distance to nearest): Well, 50. Foundation...- V__ Property Line _ r " 'Al k SEEPAGE PIPS m/]6epth Size ��--Nu:�m�b--er { SUMPS ❑ Distance to nearest: Well , Foundation�-•�t Property Line DISPOSAL PONDS ❑ c' ' I hereby certify that I have prepared this application and'thaf the work will be done in accordance with San Joaquin county ordina ces, state laws, and rules and,regulations of the San Joaquin Local Health,District}, r 1 Home owner or licensed agent's signature certifies the following. I certify that in the performance of the work for which this permi is issued;I shall not employ any porson in such manner as to become subject to workman's compensation laws,of California." Contractor's hiring or sub-icontracting 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 orkman's compensa- noc n 1a of California." I r� Th iicantj call for re fired i pecti Complete drawing onZr �rse `� C , } Signed 'j( Title: 'Da,,-3k ART Application Accepted by -' t- —"—Date ea Pit or Grout Inspection by Date Final Inspection by r ll bate —- A -'f— Ja Stk 4664781 ❑ Lodi 369-3621 O Manteca 823-7104" .0 Tracy $35_5385 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 RECEIVED 8Y DATE PERMIT.`Nd. INFO + EH 13-24(REV.sisz) L fl EH 14-28 1 O � © / ^•� —+��