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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOKTON, CA q Telephone ( 09) 466-6781 { 1/\ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 2 1 3 (Complete in Triplicate) ENT AL z-'iE,4 E4. , . . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein,.dese(ifs 1.<TlNiRapvication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules anAt4wib o'f`�fFie ban Joaquin Local Health District. f /r�®.� (� k' �,!a& g� !� � Lot Size PM Job Address (�` ` �, > City / ,/� Owner's Name 1 ` eA� e_, Address T7�(�� C�t2 ►` Phone 16 1 Contractor /NC/2041 M O L Address 112—L Al��cSr License No. Phone — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ l 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 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. a ``State Work Done Well Destruction ❑ Well Diameter $I/ Sealing Material (top 501 Depth ZZ, Filler Material (Below 50') __ p TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Q Installation will serve: Residence_ Commercial Other �}J Number of living units: Number of bedrooms - 1 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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 laws, and rules and regulations of the San Joaquin Local Health Di§trict. Homeowner 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 such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followi ng: '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 rn .' The pp t call for all requ' inspec' s. Complete drawing on r rs de. Signed X Title: Date: 7th i FOR DEPARTME USE ONLY Application Accepted by 4 Date ' Area JI Pit or Groutinspection by Date Final Inspection by Date 9� i 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 10 RECEIVED BY DATE PERMIT NO. +.EH 13-24 1REV.i/8 5) 7 EH 14-28