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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZEL T ON 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 Regulons of the San Joaquin Local Health District. Job Address ] 7:3 7 City Lot Size PM Owner's Name J/I1'lr.If'/�e'�iGl�+� Address , Phone r Contractor Address O, Tc , . Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT- ❑ DESTRUCTION L1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ,, CONSTRUCTION'5PECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca y. Ria:'of Well L Excavatio r.j, Dia. of Well Casing ., rN. Specifications 11 Domestic/Private ❑ Gravel Pack ❑ Tracy a,-, TypeofCasing -;� V rPublic 1-1 Other F1 Delta 'Depth of Grout Seal Type of Grout . I I Irrigation —_Approx. Depth i I Eastern Surface Seal Installed by - r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) r 4 Depth Filler.Material (Below 501 TYPE OF SEPTIC WORK: ;NEW INSTALLATION i l REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is i / available within 200 feet.) Installation will serve: Residence v Commercial_ Other sG>✓ Q �CCrS`, �` s Number of living units: __/_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LJ Type/Mfg Capacity• No. Compartments r PKG. TREATMENT PLT. ❑ n ; - Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE No- & Length of lines Total length/size a�'o FILTER BED Distance to nearest: Well �iaw Foundation j6go*0 ,,Property Line SEEPAGE PITS I 1 Depth Number I . SUMPS L] Distance to nearest: Well Foundation Property Line l DISPOSAL PONDS ❑ r I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and E 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 become subject to workman's compensation 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." The applicant must call for ail rquirOp inspecti ns. Complete drawing on reverse side. Signed X „-� Title: Date: i p OR DEPARTMENT USE ONLY Application Accepted by -' Date Area Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: I� Stk 46&6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M5 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE rAMOUNT REMITTED CK RECEIVED BY. _ - DATE_ ._.- PERMIT'NO.= INFO ---CASH 1 + EH 13-24(REV.I/n 5) y� I - —EH 14-26 - ax.,. ` 4 �.