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1 I APPLICATION FOR PERMITI p SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,•STOCKTON.,CA- i Tele hone (209} 466-6781 P 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 No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. pwf ,�� 1 s rg�, O r: —�j' `_j ' r" z „ V L +�`Sl ° ' ;^City /L�1" Lot Size l -. ; ry PM Job Address ` O JV _ Phone " :V� -� Address Owner's Name �" _� Contractor Address License No. Phone TYPE OF WELL/PUMP:I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 0 DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ DISPOSAL FLD. PROP. LINE t, j 1 # FOUNDATION' AGRICULTURE WELL i OTHER WELL PITS/SUMPS INTENDED USE R TY15E OF WELD;� ;PROBLEM AREA CONSTRUCTION SPECIFICATIONS F El Industrial ❑ Open Bottom _ ❑ MantecaDia.of yell.Excalation Dia. of Well Casing 1h T Specifications ❑ Domestic/Private �``❑Gravel Pack ❑ Tracy ,ype of,Casing ❑ Public ❑ Other IDDelta Depth of.Grout Seal Type of Grout ❑ Irrigation i ---Approx. Depth ❑ Eastern + Surface`Seal Installed by t I° — .> i State Work Done { Repair Work Done F-1Type of Pump H.P. Wel! Destruction EJWell Diameter Sealing'Material (top 50') l Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is E available within 200 feet.! Installation will serve: 'Residence X" Commercial Other Number of livingunits: Number-of bedrooms _ L Character of soto a depth of 3 feet: - t` Water table depth V�� SEPTIC TANK it 3 ;Type/Mfg �2/✓/� Capacity ;o -V-'99 No. Compartments PKG. TREATMENT PLY. ❑ Method of Disposal Distance to nearest:" ? Well Founda"tion_f_�.. Property Line fi 4 LEACHING LINE : l❑ No. & Length of line_ !DO s" D t :.Tgtal length/size / f `n�' FILTER BED ❑ Distance to nearest: Welles Foundation /l,° f Property Line !/ a SEEPAGE PITS [X Depth .2 S~ Size ?"'♦ N 'mber SUMPS - EJ Distance to nearest:" Well/ Foundation+;,1Property Line DISPOSAL PONDS r ❑ •= hereby certify that Nave prepared this application and that the work will be done in accordance with San Jbaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . r x, Home owner or-licensed agent's signature certifies the following: ,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 I certifies the following: "I certify that in the performance of the work for which tKis permit is issued,I shall employ persons subject to workman's compensa tion laws of Californii�, rti ¢s The applicant/must call for all required insp ctions. C mplete drawing on reverse side. !/ Date: I � -3 Signed X Title: FOR DEPARTMENT USE ONLY L ! ,, Date r� a Application Accepted by "� Pit or Grout Inspection by ` Date Fina! Inspection by Date ditional Comments: Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C `� RECEIVED BY DATE PERMIT'NO. LNF + EH 13-24(REV.7 i n 51 "�(.,1 \ �" { Y' _,. {-- EH 14-26 -