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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 Rules and Regulations of the San Joaquin Local Health District. i Job Address (0J 6y nLxu� - City Lot Size �%lA- PM Owner's Name Address `��.�J� �� Phon ' ` r r LJt) U �_�AA (R Phone 0 Contract Address Q License fJa.�A 2 p SInS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DF,STRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D 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 9 El Domestic/Private C Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public n Other L_7 Delta Depth of Grout Seal Type of-Grout- - I I Irrigation _Approx. Depth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. -.-";,State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 W Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIRY.ADDITION 13 DESTRUCTION 1) (No septic system permitted it public sewer is available within 200 feet.] Installation will serve: Residence Commercial_ Other Number of living units: 4 Number f b dr ams Character of soil to a depth of 3 feet: ., (Water table depth SEPTIC TANK Type/Mfg"' - Capacity too D / No. Compartments O PKG. TREATNIENT.PLT. ❑ / \f 1/Method of 01posal Distande to nearest:• ]Nell Foundation Property,Line S + LEACHING LINE No. & Length of lines Total l-length/size 1 X FILTER BED ❑ Distance to nearest: Well 0 Foundations Property Line 77'5'_+ SEEPAGE PITS Depth Size Li a Number f --��- aeT� �� T� SUMPS L-1 Distance to nearest_� t` _Well� Fo nu dation b + Property,Line DISPOSAL PONDS ❑ 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 Local Health Dii'trict! 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." Contractor's hiring or sub-contracting signature certifies the following:'"I certify that in t_he_pe_rformance of the work for which this permit is issued, I.shall employ persons subject to workman's compensa- tion laws of California. -" -r- — ,. The applicant call for qu"ed inspections. Complete drawing on reverse side. r"`} Signed X Title: V ,P Date: tyrl _ ` 1 OR DEPARTMENT USE ONLY Application Accepted by r� L �� Date Area f Pit or Grout Inspection by Data Final Inspection by /64& Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca.. 823-7.104- _0,Tracy B35-63I35'r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTEOy CASH RECEIVED BY DATE PERMIT'NO. +.EH1324 IREV.t/n 5l EH 74-26 !L `