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�] r APPLICATION FOR PERMITI, J � } � SAN JOAQUIN LOCAL HEALTH DISTRICT f� j1 . !t 1601 E.HAZE T ON AVE,,, STOCKTON, CAr8 . Telephone (209) 466-6781 '3 - �q$; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN 40,63 :•�# v . _ F r:;^�1.,or (Complete in Triplicate) Di CALL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. ThU1 19lication is 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.,�,ag,.s Job Address ~City' '' �'r� i,�e PM Owner's Nam �`�� - Address / d ��' Phone Contractor's Name �- �`I License:No. 16 -2 3 73 — Phone 46 t4 ��2 do TYPE OF WELL/PUMP:. �* NEW WE LVP I WEL'L..REPLACEMENT DESTRUCTION -' PUMP INSTALLAYION',,C.�'y�`_ „ 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 Cl Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of-Well Casing �. Il?115omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications . ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depths ❑/Eastern Surface Seal Installed by Repair Work Done fType of Pump H.P. � >� State Wark Done r Well Destruction ❑ Well Diameter Sealing Material(top 50') - Depth Filler Material-(Below 501 C>� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 0Q available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms E Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT:❑ '� Method of Disposal Distance to nearest: Well " Foundation Property Line t LEACHING LINE ❑ No. & Length of lines %' Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation—,Property.P.roperty Line.-. SEEPAGE PITS ❑ Depth Size Number " 'SUMPS ❑ Distance to nearest: Well Foundation Property Line " DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance.with Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f 1 Homeowner ed 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 a person in s h manner as to become su t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifiesJ&following: "I ertify that in th or nc of the wo for which this permit is issued,I shall employ persons subject to workman's compensa- tion laof Calif rnia." `� , The plica t 1 or all r c" s. Complet drawing on re side. Sign Title:. r Date: FOR DEPARt IV7,USE ONLY Application Accepted by Date 2-v Area Pit or Grout Inspection 6y / p Date Final Inspection by Dater, Additional Comments: 0 C Ut W z n�� '^ `� �z� ZV , 11114 f��L--W/� —•`,,,'///}}}, ❑ Stk 466-6781 ❑ Lodi 369-3621 . ❑ 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 "~ *� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY , DATE ZPEIT'NO.INFOEH 13241REV.14)831 �� EH 14-26