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i APPLICATION FOR PERMIT 4 47 SO SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA R 1 Telephone (209) 466-6781 � y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 2 1 (Complete in Triplicate) ENVIRONMENTAL FVLT�j Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the �s f app tcation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the u e�4,I)gS0916f San Joaquin Local Health District. 9 1 Job Address City Lot Size �j PM LL Owner's Name �� __ Address / T i Q�f!-t.r�J d`�' Phone / f—6 73_ Contractor w""'" Address - "� -License No�G Phone 9� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ '`s- SYSTEM REPAIR ❑ f OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ri Public f] Other ❑ Delta Depth of Grout Seal Type of Grout I✓Irriaation. _-Approx. 0 _zli. I 1 Eastern Surface-Seal Installed by Repair Work;Done ❑ Type of Pump , H.P. - State Work Dane L. Well Destruction 0 Well Diameter Sealing'Material (top 501 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I {No septic system permitted if public sewer is * available within 200 feet.] Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms e Character of soil to a depth of 3 feet: '* Water table depth SEPTIC TANK ❑ Type/Mfg Capacity'. . No. Compartments PKG. TREATMENT PLT. ❑ `;� Method of Disposal Distance to nearest: Well Foundation v Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line MR SEEPAGE PITS I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. 1 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 suh-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,'l shall employ persons subject to workman's compensa- tion laws of California." h The applicant ust cell for all req ired inspections. Complete drawing onreverseside. Signed X— C ` ` T7tle: `(" !� Date: r FOR DEPARTMENT USE ONLY 3 " Application Accepted by Date � � Area :;?1.7 t QI Pit or Grout Inspection by Data Final inspection b*__9 Additional Comments: -* vCli& v po t s p k b- ter-,,lcR Y ❑ 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. ox 2009, Stk., CA 95201 IK 0 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 1 -21]REV.5/x 51 EH 1I4-211 �i-r