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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ S 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 a 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 Addresslf �/ �—+ ` 6 /t�'�.„ lr, � �' `C -*t Size PM Owner's Name d%S Address 4— .11;72ew uzoff) Phone w Contractor �VloabAddress A' r' License No. Phone ! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPE TF4£ TIONS ❑ Industrial ❑ Open Bottom teca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing ifications 1 1"1 Public ❑ 0 f_� Delta Depth of Grout Seal Type of ut I I Irrigation —.-Approx. Depth I I Eastern Surface Seal.Installed by Y Repair Work Done Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth -Filler Material IBelow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I I DESTRUCTION o septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms ) Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK a ❑ 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 SEEPAGE PITS I I Depth Size _ Number I 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 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 applic t ust call for all required in a sons. Complete drawing on averse side. Signed Title: / Date- FOR DEP TM T PSE ONLY Application Accepted by Date ( `I/ "/, Area Pit or Grout Inspection by Date Final Inspection by_��ZG Date � Additional Comments: �/�i f S G Z-'3� ZSO_ 7 2 7— 6 5� 7 3�.7 LI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca f 823-7104 1 ❑ Tracy 835-6385 U /tea Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave„ P.O. Box 2St ., CA 95201FEE INFO AMOUNT DUE AMOUNTrREMITTED CXSR K RE EIVED BY DATE PERMIT*NO. EH 13-24+ lREV:fiHs1 _ � .�� tp . X1 EH 14-28, 11 �s9-oto