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t APPLICATION FOR PERMIT �5 SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA -Telephone (209) 466-67$1 10 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , . l (Complete in Tdplicate) t Application is hereby madetothe San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs application is k 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 Local Health District. M. i Job Address fe 11 K -+0_ + mil fJ PCO City Lot Size 7�x / PM I t I Owner's NameI '1"10-Sn h Address 6Phone O c_J a Contractor Address License No. Phone TYPE OF WELL/PU Pa NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' '1� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ kDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL SUMPS INTENDED USE TYPE OF WELL ' PROBLEM AREA CONST ECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ricy Type of Casing Specifications 11 Public ❑ Other ' ❑ Deita Depth of Grout Seal Type of Grout LlIrrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work CO Type of Pump H.P. State Work Done W ruction ❑ WeII Diameter Sealing Material (top 50') .I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is I I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r t Number of living units: Number of bedrooms + Character of soil to a,depth of 3 feet: Water table depth y SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PL-ri"❑ '" '- � Method of Disposal Distance to nearest: Well Foundation- Property Line + I t LEACHING LINE ❑ No. 6 Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑. 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. 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.' F The applicant must call f r quir inspections. Complete drawing on reverse side. Signed 'I Title: _(�!�/�� Date: .__7� g 6 FOR DEPARTMENT USE ONLY Application Accepted by �"�"' Date 4� Area I Pit or Grout Inspection Dy Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ L& 369-3621 , 4 Cl 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 35201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE •PERMIT'NO. + EH 13-24(REV.i/a 57 a V _V F EH 14-28 I ✓ � V /��