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APPLICATION'FOR PERMIT SAN JOAQIUIN LOCAL HEALTH DISTRJGT 1601 E. HAZEL T ON AVE., STOCKTO ,� r Telephone (209) 46828= PERMIT EXPIRES 1-YEAR FROM DATEII 'SUED^ (Complete in Triplicate) ��i�[�w, s. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or irfsts tllt�_wp'rk riereeinn described. This application is t �- made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump,andIR wules and Regulations of the San Joaquin Local Health District c Job Address City Lot Size PM Owner's Name j – p rZ Address Phone Coja ,� _nI ntractor�S� w ".:ZAddress' License No. Phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPI ACEMERf ❑ DESTRUCTION ❑ PUMP INSTALLATIONS SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 17 Public n Other r ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation _-Approx. Depth 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump g6 H.P.T�� State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION Mm DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet.) " n Installation will serve: Residence� Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:i Water table depth , SEPTIC TANK ❑ Type/Mfg Capacity' No. Compartments PKG. TREATMENT PLT. ❑ ,. t Method of Disposal i Distance to nearest: Well Foundation Property Line .. I LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS r 0—Distance-to nearest: Well Foundation Property_fine 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, 1 shall not- employ any person in su r as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: " certif at in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California The applicant mus I r I r uire ins ons. Complete drawing on reverse sXA�n Signed X Title: 7 Date: FDR DE ARTMENT USE NLY r Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by d Dated f 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 -q w FEE CK INFO y AMOOUUjNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE? PERMIT'NO. + EH 13-241 IEv.ti/nb) EH 14-26,�` f G,