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13 �f4 44 ll�t tlaJ k.'hw,} 44 -a APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT li 1601 E. HAZE T ON AVE., STOCKTON, CA �,��{ i Telephone (209) 466-6781r-� �1r" t} V1Rt�` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V5 , j 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. j 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, I Jf �Z 70 � ml/ ,. .:fes=£ .z {z,r": oSizePM # Job Address - City Lt T74 Z- Owner's Name h +/ Address Phone y"""t Contracts - Address / f License :No Phone 3� �!/13 40 TYPE OF WELL/PUMP_�� R� NEW WEL ,__ WELL REPLACEMENT ❑ .. _ i DESTRUCTION El t PUMP IN ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK P•� ' SEWER LINES �_ DISPOSAL FLD. —" PflQP. LINE�(s�T { '- .- - � -FOUNDATION /�- AGR16U TURE'WELL''" °` OTHER WELLPITS/SUMPS INTENDED USE STYPE OF WELL PROBLEM AREA-, CONSTRUCTION SPECIFICATI0 S P fz i ❑ Industrial pen Bottom ❑ Manteca Ea.-cif 4ell Excavation Dia" of Well Casing d T ❑ DoesticlPrivate ❑ Gravel Pack ❑ Tracy Type-of Casing — t mSpecifications 1`l Public f Ott el i Cl De1ta� Depth of Grout Seal /~ Type of Grout__ irrigation �&.-Approx. Depth ' I I Eastern Surface Seal Installed-bV _ l - Repair Work Done ❑ Type of Pump H.P. State Mork Done r Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth p, Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION is REPAIR/ADDITION { I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence"'" Commercial_ Other ` i ' Number of living units: Number of bedrooms 4. l .` Character of soil to a depth of 3 feet: Water tattle depth r ' SEPTIC TANK '❑ - Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal k Distance to near �, Well Foundation Property Line LEACHING LINE' ❑ No. & Length of lines Total length/size ! ..FILTER BED. ❑ Distance to nearest: Wellndat,.n Property Line i E SEEPAGE PITS l I Depth! Size Number SUMPS _r_r CllJlstance to nearest;.- 1 _ Foundation Property Line_ DISPOSAL PONDS ❑ "I 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, l 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 com_ pensa- tion laws of California." ii The applicant mu I for all re yyed "Inspections p ete drawing on reverse side" f t Signed X tile: Date: > j } + FO�t-Bf�PAIjIM T USE ONLY Application Accepted by // Date Area ` fA # r Pit or Grout Inspection by Date ° Final Inspection by"A_L( Date/ Additional Comments, - - s`° :i❑'Stk _466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t ,l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton_ Ave., P.O. Box 2dO% Stk., CA,95201 4 f yx,q 3 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. CK 9 INFO t + EH 13-24 IREV.I/n sl - S�1c� ��'1I�L I EH 14-2a