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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 i (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 Ryles and Regulations of the San Joaquin -Local Health District. « , ^' - ' k y t � S^ (fes �, , at,; ,±tsiL� r !M i3/•.�&' Lot"size �� PM Job Address 11;. �, t. fi /� 1' ( : gLV-zi XLI?Ls &.�—dress` Z��'�(!e A6' 4-$ /�A4 _ Phone O.? Owner's Name�.� Contractor ess. - a ,&Mnegeucense No Phone_ 3N13 TYPE OF WELL/PUMP:- _ `"'_NEW W LL'❑' _ '�"WELL`"REPLACEMENT. ❑ - DESTRUCTION"_❑ "- i T PUMP INSTALLATION SYSTEM'REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 13 Industrial; ElOpen Bottom LJManteca Dia. of Well Excavation Dia- of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ' ❑ Other ❑ Delta Depth of Grout..Seal Type of Grout ❑ Irrigations .y- -t ---Approx."Depth ❑ Eastern /Surface Seal Installed by Repair Work' bone Type of Pump H.P. f l State or one 6Y Well Destruction 'Ll Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within-200_feet.) Installation will serve: Residence� Commercial— Other t Number of living units: Number of bedrooms 1 ,, Character;of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK. El Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �r Distance to nearest: Well Founds tion Property Line LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE'PITS Depth it _4 71 Size Number SUMPS , +❑ Distance tomearest: Well Foundation Property Line DISPOSAL PONDS it❑ air I hereby certify that I have prepared-this application and that the-work will be done in accordance with San Joaquin couw nty ordinances, state las, an rules and regulations of the Sari-Joaquin.L'ocal 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 ams to.become subject to wbekman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following: `1 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 �ust call fo all required inspections. mplete drawing on reverse si . Ii 2 Signed' Title: Date: FOR DEPARTMENT USE ONLY Application-Accepted by; Date Are _: -l' Date`-Ii r Pit or Grout-lnspection-"byk Date Final Inspection by xx Additional Comments: - I ❑ Stk 1 466-6781 Lodi 369-3621 ❑ Manteca 823-7144 t` ❑;Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Seivices 1601'E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 # FEE ;AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE LPERMIT"NINFOEH 13-2 lREV.I%B t EH 1428 f t