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f 7� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . Uib r b 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 52091 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 Addresslk T_ City of ize PM tib r� Owner's Name Tt"W's, --- Address Phone Contractor r FJ Address License iVo. Phone_ TYPE OF WELL/PUMP: NEW WELL C7 WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k 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 ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications rt f'l Public y ❑ Other € 17! Delta Depth of Grout Seal Type of Grout _ I i Irrigation -� Approx� Depth I 1 Eastern Surface Seal Installed by i - Repair Work Done ❑ Type of Pump H.P.- 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 501 Depth - ° Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other.:_ 'S V, W%A 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet} _ Water table depth SEPTIC TANK ❑ TypelMfg,. Capacity �� No. Compartments PKG. TREATMENT PLT. ❑ //6r:•- Method of Disposal Distance to nearest: Well t Foundation ;�/-1";rProperty Line I ' LEACHING-LINE ❑ No. & Length of lines 1-4eTonal length/size X x FILTER BED ❑ Distance to nearest: Well _ Foundations Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS ❑ Distance to nearest: Well 'Foundation Property Line 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 taws, 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." r The applicant must call for all requirod'I tions. Complete drawing on reverse side. Signed X F�1 ,� ] /�_r _ _ Title: rr `�_ date: f'� R DEPARTMENT USE ONLY ot Application Accepted by _ Date Area 117 or Pit or Grout Inspection by Date Final Inspectionby Date S rY l+t4r7 c- S. Additional Comments: it L r rz_aZ1 �>' � L_ ....._ � � ❑ 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 JFEE INFO AMOUNT DUEy AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. x s EH 14-28 '1 f