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� I APPLICATION FOR PERMIT ,J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE, STOCKTON, CAS Telephone (209) 466-6781 N7 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 hereinydescnbed. This application is made in compliance with San Joaquin C_dunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.' Job Address /?-6-9' So.Dir!.��iC �+E / �T :Sor !jV City Size PM S"Sea. aC/L°f�Go�G ^'�1U Owner's Name ��—��ASO N Address Phone t Contractors Address License No. Phone TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP IN ST TION ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. I IIfs 1 FOUNDATION A LTURE WELL OTHER W PITS/SUMPS l INTENDED USE TYPE OF;WELL PROBLEM AREA C PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Exc n Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout ❑ IrrigationZ ___4p epth ❑P Eastern Surface Seal Installed by Repair Work Done Cl T of Pump ! H.P. State Work Done Well Destruction Well diameter Sealing Material {top 50'I t ` Depth I Filler Material jBelow 501 TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence Commercial_ Other ` E Number of living units: Number of bedrooms tr Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ¢ f Method of Disposal Distance to nearest: "'Well Foundation E Property Line LEACHING LINE'S ❑'^No:& Length-of lines Total,length/size FILTER BED ❑ Distancetonearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth r� Size Number SUMPS ❑ Distancerto nearest: Well Foundation Property Line DISPOSAL PONDS ❑ L 7 I 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 N rules and regulations of the San Joaquin Local Health District. I , sl 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."Contractors 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." - Th cant ust call for all required i Octions. Complete drawing on reverse side. Signed X e !�o-�� Title: + Date: ��1eq FOR pARTMENT USE ONLY i /�' Application Accepted by x Date �� Area t � Pit or Grout Inspection by _ DateFinal Inspection by �' DateLam- /? L Additional Comments: ` , ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Mante 823-7104. 0-Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:. CA 95201 FEE AMOUNT DUE i AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO + EH 13-24IREV.iiR�1 00 as , j ti■ �..ys� EH 14-25