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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)/i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work In as 11 This application 1s i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations o e San Joaquin Local Health District. ;. eT �:- - tot Size PM • Job Address City Phone Owner's Name �.,;. eJ� Address' v f �`+��Phon I Address Conti actor License No. WEL-L REPLACEMENT El DESTRUCTION LJ'i TYPE OF WELL/PUMP: NEW WELL ❑ 'SYSTEM REPAIR Ll OTHER El '--�- PUMP INSTALLATION ❑ , SEWER LINES DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Weil Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private " l:] Gravel Pack EJ Tracy Type of Casing Specifications i r ❑ Oth_er ❑ Delta Depth of Grout Seal Type of Grout Cl Public � � ,y E) Irrigation _—Ap rr-05w Depth❑ Eastern � :Surface Seal Installed by N State Work Done Repair Work Done El Type of Pump• A - - f n — %A' y ' Well Destruction [IWell Diameter. Sealing Material (top 501 Depth Filler Material (Below 50'I No TYPE OF SEPTIC WORK: NEW INSTALLATION y❑ REPAIR/.ADDITION DESTRUCTION Llavailablelwithin 200 feet.) if public sewer is r Installation will serve:%..R ,denc Commercials Other Number of living units: _�'Numbegkof.bediooms`"� f 4 .Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK E3TypelMfg I, Capacity No. Compartments •'�"'' +..�; i *(, , Method of Disposal j PKG. TREATMENT PLT- ❑ • - r ��Foundation Property Line a Distance to nearest: Well;•-ll _<i;" Total I}ngth/s a LEACHING LINE ❑ No. & Length o'lines • Jrproperty Line `*,,K.: n _ "Foundation`' FILTER BED ❑ Distance}},to nearest: Well — . ❑ Depth Size Number SEEPAGE PITS / " mFoundatibr�a0 Property Line . SUMPS U. Distance to nearest: 1 Well- / �—� � DISPOSAL PONDS ❑ I hereby certify that I have prepared this app(cation and that the work will be done in accordance with an 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 I employ any person in such manner as to become subjsignature ect to workman'"s compensation laws-of.Cal'rfornia..' Contracgo nhiring subject to workman's-contracting I certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ p f tion laws of California." vk, The applican t.call for a d inspectiolns. Complete drawing an reverse side. ` �.,, �� Title: "- f�:Irl�ls�� Date: Signed X_ """'- FOR DEPARTMENT USE ONLY ji� t Date Application Area Application Accepted by Inspection by Date �r GroFinale Inspec ut 7MS, ction by Date - Addrtianal Cents: �,�5 ❑ Stk 466-67$1 Lodi -36'21 ❑ Manteca 823-7104 Tr y- Applicant- Return all copies to: Environmental Health Permit/Services 1601 Haz ton Ave., P.O.,Box 2009, Silk., CA 95201 1 • FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT"NO. 7CASHINFOEH 13.241REV.tiH51 �� . C'��7 0 EH 14-26