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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 EXPIREiiYEAR FROM,D.ATE ISSUED. .. _ (Complete in Triplicate),. c F 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/puinpand the-Rules and Regulations of the San Joaquin Local Health District. .. Job Address U City IraC a Lot.Size PM C -.. . C�Z �/�-t ✓Z�Q�CI �Q Vel . Phone 7� Owner's Name �' �L ��' �>� _ � Address e Contractor's Name aLc7 P s License.No. Phone TYPE OF WELL/PUMP: NEW WELL CJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r' Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is a' available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units:I Number of bedrooms 3 -- Character of soil to a depth of 3 feet: 4DO 9E Water table depth �' D SEPTIC TANK Type/Mfg Cmt4.eiteT6 Capacity /5bi) No. Compartments PKG. TREATMENT PLT: ❑ 20! Method of Disposal .0 Distance to nearest: Well ® ¢Foundation Property Line 7 a O 4t LEACHING LINE No. & Length of lines r Total length/size L/ d FILTER BED .Distance to nearest: Well 40 Foundation S d Property Line DD SEEPAGE PITS ❑ Depth /O SizNumber SUMPS ,e Distance to nearest: Well.� iQr Foundation f-0 Property Line l DISPOSAL PONDS ❑ I hereby certify 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 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." Contractors 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 must call for all required inspections. Complete drawing on reverse side. Signed X (, - ��s _ Title: (1 Date: l S FOR DEPARTMENT,USE ONLY r Application Accepted byDate _� Area Pit or Grout Inspectio Date �' Final Inspection by CJOs ^�+._ Date 4X:� Additional Comments: ❑ Stk 466-6781 11Lodi 369-3621 ❑ Manteca 823-7104 E] Tracy 835-6385 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. . /`��• +EH 13-24 4REV.101831 EH 14-28 �S c7' G�