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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. _ / � `Joh AddresA� _Q 1 City Lot Size! _ PM Je �� - • g- Owner's Name' Address Phone Contracto ljm,& CIEZAddress 6 License No. a Phone TYPE OF WELL/PUMP: 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by -Repair Work Done . -❑ Type of Pump -- - H.P.. - - -' " - State Work Done- Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Fillet Material.{Belo -50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ (REPAIR)ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is�, b _,., ..._- ,,.._-- / I f — - —_-- -—�-'_`-'"available-within 200 feet.) - -- Installation will serve: Residence— Commercial— Other Number of living units: Number of bed oms y r Character of soil to a depth of 3 feet: -� � � �t-Water table depth SEPTIC TANK ❑ Type/Mfg Capacity !.No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well Foundation Property Line (a LEACHING LINE 11'�ND. & Length of.lines � ` qrs Total length/size." FILTER BED ❑ Distance to nearest: Well "TO Foundation /Q` Property Line` . L SEEPAGE PITS ❑ Depth r �o� ' Size_ a ��.� If Number ' SUMPS Imo' Distance to nearest: Well inn f Foundation /Li Property Line F.S DISPOSAL PONDS ❑ 1 1 hereby certify that I have prepared this application and that-the.work will be done in accordance withlan`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, 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 certify that in the performance of the-work fdr which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." -,-r` ti ' The applicant mus II for allZruiredAnspections. Completedrawing-on reverse_side.-' _ Signed Title: to. �S r FOR IEPARTMENT USE ONLY Application Accepted by + -c Date 9 r�J y06 �'Afea , � � Pit or Grout Inspection by Date � Final Inspection by .~• Date Additional Comments: " + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appficant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009' Stk., CA 95201 I FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH s � p +EH 1324(REV.1/a 5)EH 14-26 r _7Q, -�