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��. APPLICATION FOR:PERMIT f . SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephoned(209) 466-67781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)Ir 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. F Job Address AD City /� :. Lot Size PM L� Lp►d'Gs - Phone Owner;s,Name Address y � -7-01 - � s F_ Contractor's Name "e License s No. ire 9.s — Phone TYPE OF WELL/PUMP: NEW WELL 6&— WELL REPLACEMENT 0--- DESTRUCTION 2�-� { -PUMP INSTALLATION A--" SYSTEM REPAIR ❑ OTHER-fl— DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL * *.PITSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑"�ndu trial ID Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing 'Domestic/Private ❑ Gravel Pack C Tracy Type of Casing G _ S.pecifications O Public ❑ Other ❑ Delta Depth of Grout Seal _1,1f12 Type of Grout��,r�Td r✓7<_ ; ❑ Irrigation pprox. Depth ❑ Eastern Srace Seal Installed by Repair Work Dane ❑ Type of Pump e!:�� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 / Depth Filler Material (Below 50'1= TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION C1 (No septic system permitted if.public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other L s ' t_ 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.Compartrtlents. PKG. TREATMENT PLT. ❑ Method of Disposal�' Distance to nearest: Well Foundation Property Line x + _ LEACHING LINE ❑ No. & Length of lines ^ �A ' Total ierigttl/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lin, , y SEEPAGE PITS ❑ 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 ac6ordance 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 s ch er o become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin ." ce t i the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif i The applican c f r ui . Co late drawing on reverse side. r/ t Signed Title: Date: 101p-t1SE-ONLY G -- Application AccepteAby Date �� ` �— AreaPit or Grout Inspectto G li`1 Final Inspection by Date { ►. K' Additional Commen kr ❑ Stk 466-6781 F Lodi 3W3&1 ❑ Manteca 623-7104 ❑ Tracy 835- �Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., 95201 f ` FEE •- INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. +EH 13-21(REV.WWI � a� �= EH 14-28