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APPLICATION FOR PERMIT Movcf_- ii_t!) SAN JOAQUIN LOCAL HEALTH DISTRICT `Ti ,Vlv % }etv 1601 E. HAZELTON AVE., STOCKTON, CA 0 LV%wvc N Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) N9�►.he�,�f3wr��'Y- f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h rein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin � Local Health District. fjfJl � `r h City c �_ Lot Size !/ PM ral Job Address ,C W Owner's Name jl� iri✓ �l Address 6 6/1 Phone Contractor Lp Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR d OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES % DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other C1 Delta Depth of Grout-Seal w_M Type of Grout _ I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done , 1 Well Destruction ❑ Well Diameter Sealing Material (top 50'0, Depth Filler Material (Below 501' -- � i] TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is V_ :,available within 200 feet.) Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms f Character of soil to a depth of 3�feet:.. .... - - --- - -- - Water table depth T SEPTIC TANK .__5—Ty—y pelMfg apa i No. Compartments r y, PKG. TREATMENT PLT. 13r- pY��r pP� �tl td�t Method of Disposal l Distance to nearpermii•m 1 have A6tMtfa to. Property Line { U LEACHING LINE ❑ No. & Length Ai rr _- JDR�length/size FILTER BED t I] Distance to neareb5� 4� L ' oundation Property Line I i SEEPAGE PITS ,1 I 1 Depth Size _ Nuriber SUMPS ❑ Distance to nearest: Well Foundation I Property Line I DISPOSAL PONDSp__.__� __.,._ T• .e„ - _ �.- ..__.-.... ._ I hereby certify that I 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 shall not employ any person in such manner as to became 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californiai." r The mspeCtion Complete applic t drawing on reverse side. Signed � int.call for all requi i"„''_ "'"� �— Title: CelCle_ Date: ] R DEPARTMENT USE ONLY waai Application Accepted t . wK a Vin+ r _ Data Area by Pit or Grout Inspection by. Date Final Inspection by Dat e. Additional Comments: ❑ Stk ;466-6781 ❑ Lodi 369-3621 ❑Manteca 823-7164 ❑ Tracy 835-6385 ,`Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.'O. Box 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. # INFO 0 �^�} tEH13-241REV.riael aSr4� ms's T"� -AW77 EH 14-2e