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0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA # Telephone (209) 466-6781 F 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 t. Local Health District. I ,�} . Job Address - City/TeAY Lot Size�L•(1 PLa PM Ir �i F Owner's Name Address -7 5 c/ Phone ContractorVJ)12-41 Address License Nv_ R � Phone Z,q::__2 r—TYPE-OF-WEL-L/-PUMP:-- -t -N -WELL-Y- WELL-,REPLAC-EMEN-T❑— -DESTRUCTION-O -�- PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ A ' DISTANCE TO NEAREST: SEPTIC TANK .�/o _t SEWER LINES." � DISPOSAL FLD. PROP. LINE + FOUNDATION _:S2 AGRICULTURE WELL OTHER WELL PITS/SUMPSAZ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial 'Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � i P�-� f Specifications /7 f`1 Public Cl Other n Delta Depth of Grout Seal pe'af r ut 0,--m i°I, - I Irrigation .Approx. Depth l I Eastern Surface Seal installed by _ T Repair Work Done ❑ Type of Pump _- H.P. t= -State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 O Depth Filler Material /Below 501 --- - `' TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION,f I DESTRUCTION I I (No septic system permitteiddf public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other ; Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: ^-^ Water--table-depth SEPTIC TANK ❑,, Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑'. k Method of Disposal (` l ''Distance to nearest: Well Foundation Property.Line � 1 LEACHING LINE ❑ ; No. & Length of lines _ Total length/size ^f FILTER BED ❑ Distance to nearest: Well --� Foundation Property Line /V SEEPAGE PITS I 1 Depth Size _ Number SUMPS Ll" Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 all required inspections'Complete drawifib on reverse sine: Signed X A / l !/JIA_ � 6"AAA.:-��- TitleE Date: 4D FOR DEPARTMENT USE ONLY Application Accepted b Date Area I� Pit Grou Inspection bye r Final Inspection by ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO CASH 9 *.EK 13-24(REV.t/11 5) 1 �S v EH 14-28 Illlll 3