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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. Job Address -I 'er) City JTe1*J Lot Size ©dZ PM Owner's Name ✓1!� �� C/ CA Address Phone lo[C,4:0,ti C/Q PV-,P,7 Contractor zt aAddress . 46-G07 3 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. 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 A, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications v" ❑ 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 (top 501 Depth Filler Material (Below ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION STRUCTION ❑ (No se')Stli:system permitted if public sewer is /� available within 200 feet.) Installation will serve: Residence" Commercial_ Other I_ Number of living units: —L Number of bedrooms — Character of soil to a depth of 3 feet: ater table depth 'f SEPTIC TANK ❑ Type/Mfg _ -Ca city I o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propert�Line LEACHING LINE Ft No. & Length of lines "' X d ! Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS (Depth �� Size Ir Number SUMPS ❑ Distance to nearest: Well j04 Foundation /(,T r Property Line l'6 DISPOSAL PONDS ❑ 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 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 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 applicant must for all re fired ins ctions. Complete drawing on reverse side. / Signed X Title: �.� Date: FOR DEPARTMENT USE ONLY Application Accepted by I� �, Date �`b-0 � Area M� l� Final... __.. _ _.r�..,__......____ �---.�_. .. A Date Ins tion b Date Pit or Grout Inspection b P� Y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH +7 + EH 13-24(REV.1/e 5) 1 10 41 t 9C4 EH 14-28 1