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fl APPLICATION FOR PERMIT SCANNED r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209M 466-6781 w� '! PERMIT EXPIRES TYEAR FROM DATE 1SSUED6'�° (Complete in Triplicate) U'.• Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thL-w rh-heP,ei®:descnbediE iLl' lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the t� e i s Iae San Joaquin Local Health District. TkY, / CI� a Job Address . t City Lot Size PM � g Owner's Name �� Address�ClGi& 77, &_c a.1 �� Phone F Contractor �- Address 1 I License No.26 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION, SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE � a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIdks , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5-5omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t f7 Public L) Other ❑ Delta Depth of Grout Seal € Type of Grout I I Irrigation Approx. Dept I 1 Eastern isurface Seal Installed Repair Work Done LDmp lcType of Pu �- H.P. l - State Work Done- h,-Ae+-U— Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION {.I DESTRUCTION I I (No septic system permitted if public sewer is available;within 200 feet.) Installation will serve: Residence_.._- Commercial_ Other r Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E) Type/Mfg Capacity No Compartments \`/ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING:LINE.❑.R,.No...&,.Length of lines.. Total length/size:v FILTER BED ❑ Distance to nearest: Well. Foundation Property,Line SEEPAGE PITS I I Depth Size ~�s Number' i " r SUMPS ❑ Distance to nearest: Well FoundationProperty!Line° DISPOSAL;PONDS-_.:. F)—K , 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. i 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 j 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 call f r all required inspections. Complete drawing on reverse side. I L t F Signed,X �✓-�-v.�a�� I Date: -y �1 }! pJ r �`r ._ � '•c`� ,� I } I "ft FOR DEPARTMENT USE ONLY t )A Application Accepted by Date I� Area 0 C�_ Pit or Grout Inspection by Date Final Inspection by Date A)_/_r Additional Comments: ❑ Silk 1466-6781 ❑ Lodi 369-3621 Cl Manteca 823.7104 ❑ Tracy 635-6385 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 CK CASH RECEIVED BY DATE PERMIT-NO. T Fc P + EH 13-241pEV.t/nsy EH 14-26 - I