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�O Y L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 l 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. TMs 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 - Job Address / -o'` �' � City Q Lot Size PM ° Owner's Name Addressw�-wr1c; — = =- - Phone + rO 1 Contractor e Address _� �� License IVo. �T' Phone �6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR'❑ ; �.OTHER C1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7E DISPOSAL FLD PROP. LINE FOUNDATION AGRICULTURE WELL t OTHER WELL r - PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial El Open Bottom ❑ Manteca Dig..of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-. Specifications r A El Public ❑ Other ❑ Delta Depth of Grout Seal ,I Type of Grout r v 11 Irrigation Approx. Depth ❑ Eastern Surface Seal lnstalled by i-s N Repair Work Done❑ Type of Pump N.P. State Work Done V Well Destruction ❑1 Well Diameter - Sealing Material '.t top 5011 I ' Lt .r Depth ,i Filler Mat_eriaf (_Belo_wi_50']':�� I TYPE OF SEPTIC WORK="-"NEW`INSTAI- TION [DREPAIR/ADDITION DESTRUCTION LJ;fN6 septic system permitted if public sewer is available within 200 feet.) Installation will serve:; Residence_ Commercial_ Other Q Number of living units: --t_ Number of bedrooms Character of soil to a depth of 3 feet: I b r Water table depth O SEPTIC TANK 1 ❑ Type/Mfg s Capacity f No. Compartments P k PKG. TREATMENT PLT. ❑ ) Method of Disposal Distance to nearest: Well Foundation- Property_Line. i i I • I r LEACHING LINE s No. & Length of lines i' Total length/size FILTER BED C3Distance to nearest:_--Well _Foundation /0 If- Property Line SEEPAGE PITS Depth Size t �� '� Number : SUMPS ❑ Distance to nearest: WelleaL�_ Foundation °Y.W*'4 Property Line DISPOSAL PONDS I ❑ 1 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 Local Health District. Home owner or licensed agent's signature certifies the following:-"I-certifythat-in-the-performahca of the work for which this permit is issued, I shall not employ any person in such manner as tabecome 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 for which this permit is issued, f shall employ persons subject to workman's compensa- tion laws of California.f VA.. `f:y / The applicant must call,for*all requ{re specti n . Complete drawing on reverse sive. f Signed r ' Title: Date: l V FOR DEPARTMENT USE ONLY Pyr Application Accepted by Date ✓ Area V r 1 Pit or Grout Inspection b Date v Final Inspection by Date I x A itional Comments: Stk 466-6781 © Lodi 369-3621 ❑ Manteca_823.7104 Ll Tracy-835-6385--i,-, Applicant—Ritual!copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE ' k INFO AMOUNT DUE AMOUNT'REMITTED CAH RECEIVED BY `DATE PERMIT NO. + EH 13-24{REV.f/s 5l EH 1426 S O,�