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APPLICATION FOR PERMIT pAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECrz1VED 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE AN Jpa.Qis;rt CGl ivF � / PlA l L (Complete in Triplicate) ENVIRONMENTAL HEALTH D114iS10N ' n is 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 I nce No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordina k Local Health District, Lot Size PM Job Address e City ' Phone _ Address Owner's'Name + (;lw (" s License No�? � Phone_ Address Contractor ' (J DESTRUCTION [ hTYPE OF WELL/PUMP: NEW WELL.❑ -WELL REPLACEMENT ❑ SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLA710N� PROP. LINE SEWER LINES DISPOSAL FLD._ ` DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITSISUMPS FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation —~— ❑ Industrial P Type of Casing Specifications XDomestic/Private LlGravel Otfier +Gravel Pack ❑ Tracy Type of Grout — 1k ❑ pelta �, , ,f Depth of.Grout Seal 1 i`1 Public t f y Surface.*881 Installed by - If I I Irrigation ..Approx. Depth I 1 Eastern + ¢ Type of Pump C+� H.P. state Work,Done T Repair Work Done � YP s Well Destruction ❑ WellDiameter % Sealing Material (top 501 Depth Filler Material,(Below 50') c syslem TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 -REPAIR]AOi]1TION`i I: DESTRUCTION E I available1w thin 200 feet.)if public sewer is _S 4-— a ' i;ty'L Installation will serve: Residence= Commercial_ Other--�— s ; r+ ; Number of bedrooms %s.f Number of living units: <" + Water table depth Character of soil o a depth of 3 fet: Capacity n 'No.Compartments- _SEPTIC TANK' Type/Mfg ._ Y. "_p- Type/Mf 1 _ g i Method of Disposal PKG. TREATMENT PLT. ❑ � x\14 - n i r Distance to nearest: Well Foundation H� ropert�y Line t 63 a x `Total'length/size LEACHING LINE Cl No. & Length of lines Property Line " FILTER BED ❑ Distance to nearest: Well Foundation P Y k Size ? - Number „`'" t SEEPAGE PITS _( I Depth f Property Line I SUMPS L� Distance to nearest: Well Foundation p rtY DISPOSAL PONDS ❑ r Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1d rules and regulations of.-the San,Joaquin Local Health District. t 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 i r in such manner asAo become subject to workman employ any person 's compensation laws of California." Contractor's or subto -co ompensa- signature certifies the following: "I certify that it the performance of the work for which this permit is issued,l shall employ psubject tion laws of California." The applicant call f rail req in Ions. Complete drawing on reverse side, �? Title: Date: � ~16 .—! Signed X FOR DEPARTMENT USE ONLY pate Area Application Accepted by - Ida4 Pit or Grout Inspection by Date Final Inspection b r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 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 95201 FEEZAMOUNTDUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFOEH 7&241REV.1/n51C' r7EH 14-26J