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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED JComplete 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 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.. r w. Job Address [V E'�l el��.. a; I C!ty � ��fLot SizeC "X o�,J PM t, �� { F} E i S tr Phone O Owner's Name�p �� , ell,. �' ; �- Address I 11 , Contractor's Name � _T_6_ � License No. 4 1 Phone TYPE OF WELL/PUMP: II NEW WELL ❑ 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 ElOpen-Bottom--; 2-Manteca , pia. of Well Excavation ' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other"-,' 1:1 Delta Depth of Grout Seal _ Type of Grout ❑ Irrigation __2�pprox. Depth C] Eastern Surface Seal Installed by d Repair Work Done ❑ Type Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 —_ Depth Filler Material {Below 501 " TYPE OF SEPTIC WORK: N REPAIR/ADDITION JX DESTRUCTION ❑ (No septic system permitted if public sewer is .II avbilable within 200 feet.) Installation will sere: Residence_W__ Commercial_ Other Number of living units: h� N,m'ber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg l i Capacity No. Compartments PKG. TREATMENT PLT. ❑ I) � ` Method of Disposal i Distance to nearest: Weil *�` Foundation Property Lire LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation-,4 - Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ER Distance to nearest: - Well rV A Foundations . Property Line DISPOSAL PONDS ❑ II 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 Looal Health-District. L L. , _ w .",4, w_ 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 certlfy';that in the performance.of.the work for which this permit is issued, I shall employ persons subject to workman's compensaj tion laws of California." The applicant must call for all requi T�pecti s. Complete drawing on reverse side. Signed Q/""� SII i Title: h _ Date: 11. FOR DEPARTMENT USE ONLY Application Accepted by Date Z Z Area u Pit or Grout Inspection by _ Date Final Inspection by Date Additional Comments: ❑ 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 AMO'NT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. INFO CASH /� + EH 1320(REV.10183) 7 �/+� - F EH 1428 II �