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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 x made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. t -K e.lAl . �q!.C;. 7- V. /) .J) A. l .4 (�� /l-� r f,. � I �. ¢;tea 77ar—ao pna I hereby-ceoty 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 fegulations 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 mall for all r red 'nspecvons. Complete drawing on reverse � s f� - Signed X Title: 1/� p• FOR DEPA TMENT USE ONLY / Application Accepted by I Date �'I Area or Grout inspection byat Final Inspection by D to Additional Comments: . -12 ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envir.onmehtal:Health Permit/ Services. 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 \`L� EEC +.EH 13-24 (REV. 7/Rs) EH 14-28 INFO AMOUNT DUE '' AMOUNT REMITTED CASH RECEIVED BY J A/ Owner's Nam f Address Phone PF r Contract J �- �GcYGs�r Address P 7 License fro. 2Z� Phan J" - �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e PUMP INSTALLATION L7 SYSTEM REPAIR ❑ OTHER ❑ +%f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v 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 1-1 Public CI Other ❑ Delta Depth of Grout Seale Type of Grout _ 1 1 Irrigation ,-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H. P. ' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1;'_- Depth Filter Material (Below 50'• li- •'' -__ _ '� C TYPE OF SEPTIC WORK: NEW INSTALLATION HEPAIRlADDITION I I DESTRUCTION I I INo:septic system permitted if public sewer is + Installation will serve: / {` f` av`ailablb within 200 feet.) Residence _✓ Commercial _ Other f`� Number, of living units: Number of a rooms r ! Character of soil to a depth of 3 feet: ��' f Water table depth C/ SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT. PLT. O . - - _� _ Distance to nearest: Y(%O �S.— .` �' Method of Disposal Well -IC Fou Foundation Property Line , a t ~ LEACHING,LINE i No. & Length of lines ' Total length/size FILTER 6E67 ❑ Distance to nearest: Well Foundation —Z- _ Property Line SEEPAGE. PITS >< Depth Size 33 Number SUMPS" 0 Distance to nearest: Well Foundation /'fl Property Line IT DISPOSAL PONDS ❑ I hereby-ceoty 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 fegulations 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 mall for all r red 'nspecvons. Complete drawing on reverse � s f� - Signed X Title: 1/� p• FOR DEPA TMENT USE ONLY / Application Accepted by I Date �'I Area or Grout inspection byat Final Inspection by D to Additional Comments: . -12 ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envir.onmehtal:Health Permit/ Services. 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 \`L� EEC +.EH 13-24 (REV. 7/Rs) EH 14-28 INFO AMOUNT DUE '' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT -NO. IV.1 00 11 Abr 00 LJ