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APPLICATION FOR PERMIT ip SAN JOAQUIN LOCAL. HEALTH DISTRICT I� 1601 E. HAZEL T ONE-AVE., STOCKTON, CA ' ; I Telephone{209) 456-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for alpermit 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. }QCg f Job Address C City Y �Q of Size tom" PM Owner's Name SILL Address Phone IM. Contractor m / !rte _Address E© y„L �R/ License No. Phone F' TYPE OF WELL/PUMP: NEW WELL ❑ WELL'IREPLACEMENT ❑ DESTRUCTION ❑ I� PUMP INSTALLATION Ll SYSTEM REPAIR [I OTHER 17y DISTANCE TO NEAREST: SEPTIC TANK �'�' SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; ,I INTENDEDil USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications € FI Public I ❑ Other n Delta Dtpth of Grout Seal Type of Grout I I Irrigation —_Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. I! State Work Done Wel! Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 _ TYPE Of SEPTIC WORK: NEW INSTALLATIO REPAIRIADDITION 12 `DESTRUCTION I Ii(No septic system permitted if public sewer is ` l rr., :available within 200 feet.) I . 1 . Installation will serve: Residence) Commercial_'i'Other Number of living units: _L_ Number of bedrooms aS r ll i Character of soil to a depth of 3 feet A0&9 J� °i {.. s Water table depth ! SEPTICTANK ❑ Type/Mfg 4�tk Capacity 116crb No. Compartments PKG. TREATMENT PLT. ❑ F Method of Disposal ' Distance to nearest: Weir At Foundation 4'f -.� Property Line /�✓'� LEACHING LINE � No. & Length of lines � 'p- Total length/size o s Mf i leT-- >peT FILTER 'BED�1 ❑ Distance' nearest: NVefl� )Foundation} Property Line ,I�iII� SEEPAGE PITS Depth II Size i M Number SUMPS l Distancel�to nearest: Well 4:0 Foundation. Property Line 9 i DISPOSAL PONDS ❑ j 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 Sart Joaquin Local Health District. 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 Homo owner 1C 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 following: "I certify that in the performance of the work for which this p&rmit is issued, I shall employ persons subject to workman's compensa- tion law's of California." jjII �� The applicant must call for requiredllinspections. Complete drawing oil reverse side. N l ' fpr Signed Title: Date: "` Ii I ' a, FOR DEPARTMENT USE ONLY, f i n Application Accepted by __ date ;Area ` V' Pit or Grout Inspection by Date •• Final-Inspection by Date Additional Comments: ❑ Stk f466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104'_� ❑ Tracy 835-6385 Applica6t- Rlel turn all copies to: Environmentat Health Permit/Services 1`601 E. Hazelton Ave., P.O. Box 2009,�Stk. CA 95201 T- INFO -- AMgUNT 0UE"' ..._AMOUNT REM,1TTED --4r-ASH —,-.RECEIVED'BY;" BATE'- PERMIT Nb` +,EH 13-24 IREV. EH 14-20 C> .-Y w._�._. _�..- ,... - -•...,. .�„ -. li -•�..7 . .. .WSJ