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I -- APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA 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 No. 549 for sewage or No. 1862 for well%pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size ply Owner's Name dE:- _ Address / � Phone a.�•,' Contractor_ — Cf Address s i License No Phone i �,"aTYf E OF WELL/PUMP: NEW WELL © WELL REPLACEMENT,,`❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ; SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES ° DISPOSAL FLb. PROP. LINE FOUNDATIO " LL. OTHER WELL PITS/SUMPS INTENDED USfa,,, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation °s Dia. of'Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac E t' I`l Public ' x y Type of Casing i I Specifications Cl Other {] Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation m _T"Rpprox. Depth 1.1 Eastern Surface Seal Installed by ` Repair Work pone L? Type of Pump r H P I { w- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') �i Depth Filler Material (Below 50') t t! TYPE OF SEPTIC WORK.; NEW INSTALLATION REPAIR/ADDITION I i DE=STRUCTION.1 1 1No septic system permitted if public sewer is ,. \ � 1. +1 �� Qr` N, # f available within 200 feet.-) Installation will serve: Residence A Commercial� Other- Number of living nits: � Number of bedrooms E 'ti i _ Character of�soil,to a depth of 3 feet: — F'✓ �, Water table depth CO SEPTIC TANK ElType/Mfg ' Capacity __ No. Compartments PKG. TREATMENT PLT.,❑ ,._. ! � Method of Disposal f Distance to nearest:"" V4lisll r'"�) posal t Foundation x I Property Line,_f�1 '�_ r LEACHING LINE No.{& Length of les + Total'length/size ; :. FILTER BEp I" T ❑w Afsfance torriearest: r'�V1lellrFoundation b., ,, 5 Property Line r' _ - SEEPAGE PITS Size Number SUMPS AL1 Distance to nearest:. �Well Foundation i Property Line DISPOSAL PONDS ❑ 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 Di$trict. Home owner or licensed agent's signature certifies the following:'9 Certrtify that in the performance of the work for which this permit is issued, I shalt not employ any person in s�ch manner as to become subj ct to workman'i"eompensation laws of California." Contractor's hiring.or sub-contracting 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 workman's compensa- tion laws of California."l r n# The applicant must call for re d inspe tions. Complete drawing on reverse side. .. Signed X - Title: k P 'bate: -' DEPARTMENT USE ONLY Application Accepted by I # Date Area Pit or Grout Inspection y R Date ' Final Inspection by Date l2 8 Additional Comments: - ' ❑ Stk 466-6781 1-] Lodi 369-3621 r Manteca 823-7104 ❑ Tracy 835-6385 Mort Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i i; a - _ s .rINFO AfNOUNT DUE" ' 'AMOUNT CK REMITTED- �" -.CASH� RECEIVED BYr '�'-IDATE� �PERMIT'NO.T tN.EH 13-24{REV. EH 14-28 - � •�