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I/ �► APPLICATION FOR PERMIT O SAN JOAQUIN LOCAL HEALTH DISTRICT =. 1601 E. HAZELTON AVE., STOCKTON, CA V1 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 Rule and Regulations of the San Joaquin Local Health District. Z 3�ZJ- Xr4ZV Job Address- ir ` City Lot Size 61614.9PM �3 .5� ►r / C�rii1 � Phone Owner's Name Address / �� 1 v Contractor Address � 9 /W, icense No. 0996 o/'3Phone �� TYPE OF WELL/PUMP: NEW WELL X, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS 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 Domestic/Private XGravel Pack ❑ Tracy Type of Casing de E 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 Diamet Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms A- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line C. LEACHING LINE ❑ No. & Length of lines Total length/size V1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 v� employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature C) 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 Calif rnia." The applicant m t call for all req r inspection . Complete drawing on reverse Ode. 12 Signed Title: Date: Y FOR DEP A TMENT USE ONLY Application Accepted by A �- Date 6'7 Area 6 Pit or Grout InspectioAb uDate Final Inspectilon,,b'y— Date Additional Commentse' t lelS - L )/tX�Y'1 �Lflja :� (? / ❑ Stk 466-6781 Lodi 369- anteca 823-7104 ❑ Tracy 835-6385 WI'l—M 5,5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St—, CFEE A j INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY / DATE �PERMIT`NO. + EH 13-24(AEV.1/a 5) —7c3 ©O f�� /3 O/fib U�O—q O O EH 14-28 f i