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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601.E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i �f (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 a made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far wall/pump and the Rules and Regulations of the San Joaquin Local Health District, application n Ls)- Job Address h , r City Lot Size /l' PM Owner's Name - a� - #----- — ddress r ; Phone - a Contractor ` Address TYPE OF WELL 111:11U11,11,111,111113: NEW WELL ❑ License No. Phone PUMP INSTALLATION WELL REPLACEMENT ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANKSYSTEM REPAIR ❑ OTHER El-l SEWER LINES _� DISPOSAL FLD. FOUNDATION _ AGRICULTURE WELL PROP. LINE INTENDED USE OTHER WELL�s�� pITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom Manteca Dia. of Well Excavation JR Domestic/Private R Gravel Pack ❑ Tracy T Dia. of Well Casing ❑ Public ❑ Other Type of Casing Specifications I'll EJ Depth of Grout Seal ❑ Irrigation /0-l�Approx, Depth ❑ Eastern Type of Grout Repair Work Done ❑ Type of Pump,-ubn�,_.1, S dace Seal Installed by — -v��ZH.P. r Well Destruction ❑ Wel! Diameter �� State Work Done' J� Sealing Material (top 501) r(� Depth Filler Material (below 50') TYPE OF SEP !C WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted ifublic S Installation will serve: Residence Commercial— Other available within 200 feet,) p sewer is � Number of living units:-4— Number of bedrooms Character of soil to a depth of 3 feet: a SEPTIC TANK ❑ Type/Mfg Water table depth i PKG. TREATMENT PLT. ❑ Capacity. No. Compartments Distance to nearest: WellMethod of Disposal �f'1 Foundation property Line LEACHING LINE ❑ No. & Length of lines LP ` :'. FILTER BED ❑ Distance to nearest: Well Total length/size J Foundation Property Line 6� SEEPAGE PITS ❑ Depth Size Number 1 SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS C1 Well _ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coun ordin rules and regulations of the San Joaquin Local Health District. ty antes, state laws, and Home owner or licensed agent's signature certifies the followinperforg: t employ any person in such manner as to become subject to wo kman's�mpensat on laws of California,"nce Contractor's work for hiring or sub-contrich this permit is acting signot nature f certifies the following: "1 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 applican st call for all req ' d i Pections. Complete drawing on reverse side. Signedxl� 44 ' 9 7 Title: Date: _ ,r FOR DEPARTMENT USE ONLY Application Accepted byOA �- Date Area O� Pit or Grout Inspection by Datel 7 FinaInspection by Dat _ �Q� ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return 811 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT N0.' + EH 14-24(REV,i/8 51 T N EH 74.28 � �j' tJ to ,r �7