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is APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON .AVE., STOCKTON, CA ± Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , I (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 1pump and the Rules and Regulations of the San Joaquin Local Health District. ap. c ou o-r Jab Address I- City LS CAS.got Size r5498<5 PM Owner's Name Address Phone . '�: Contractor's Name License No. � phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP'INSTALLATION SYSTEM REPAIR Q OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK &261QC SEWER LINES 1121606 DISPOSAL FLDV—&}F PROP. UNE/126 FOUNDATION 02&2C—'AGRICULTURE WELL 4 'U6 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC IFICATIO�� SI/ 11 Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation /�'_ Dia. of Well Casing ` Domestic/Private Q Gravel Pack ❑ Tracy Type of Casings Specifications ! .� OA ❑ Public ❑ Other Q Delta Depth of Grout Seal � � _ Type of Grout .E El Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done El Type of Pump H.P• State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEWINSTALLATION LlREPAIR/ADDITION E3 DESTRUCTION ❑ INo septic system permitted if public sewer is :ill, v available within 200 feet.l Installation will serve: Residence— Commercial Other Number of living units: II Number of bedrooms Character of soil to a depthof3 feet:- --—"-- -- �'WBter-table depth SEPTIC TANK ❑❑ ,Type/Mfg Capacity No. Compartments ~--PKG. TREATMENT PLT. ) Method of Disposal 'Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ Nolo& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property'Line i SEEPAGE PITS ❑ ;Depth Size Number -{ SUMPS ❑ "Dis"tance to nearest: Well Foundation r j Property tine I 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 Sen'Joaquin Local Health District. Home owner or licensed agent's signature certifies the fallowing: "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 applica ust call for all required 'ns coons. Com a drawing on r verse side. Signed I Title: +' 1 �� G Date: j FOR DEPART ENT USE ONLY /?_! +1� ,Application Accepted by Date Area Pit or rout I pection by I Date r�Final Inspection by Pit 016P Date ;Appiticant onal Comments:Sk 46&6781 ❑ Lodi it 365-3621 ❑ Manteca 823-7104_ ❑ Tracy 835-6385 4 - Return all copies to: Environmental Health Permit/Services 16D1`E. Hazelton Ave., P.O. Box 2009, Stk.;CA 95201 I � - FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIY'NO. I INFO _ t Ex 13-24 IREv.101831 �s ' z7o 3 " � " �'� 7 EH 1426 �� F