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APPLICATION FOR PERMIT SAN JOAO•UIN LOCAL HEALTH DISTRICT ; , 1601 .E. HAZE T ON AVE., STOCKTON, CA N Telephone (209) 466-6781 (� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � �c , nn�n•c�JZ C (Complete in Triplicate) �.odd . 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. k Job Address City � ! /�� e6e Lot Size PM 1�ti�L Owner's Name i°��° [zzter-- Address t4Phorr it / c"�� Contractor L.-_/Ji��f ' Address License No Phane �]fl TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ v-SYSTEM REPAIR ❑ OT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL —PROBLEMAaEA A CONSTRUCTION-SPECIFICATIONS- 0 Industrial SPECIFICATIONS"❑ Industrial El Open Bottom r�teca ° Dia.-of-Well Excavation pia. of Well Casing v❑ Domestic/Private ❑ Gravel Pa ❑ Tracy �.� Type ofiCasing } Specifications •+ © Public ❑ r ❑ Delta 3� Depth of Grd6t Seal i Type of Grout Irrigation _—Approx. Depth ❑ Eastern•��"'� tSurface Seal Installed by Repair one ❑ Type of Pump H.P. State Work Done 1 _Vfe�ll_Destruction ❑ Well Diameter ; z Sealing Material (top 509 4. i Depth 1 Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial Other t Number of living units: Number of bedroomsI t Character of soil to a depth of 3 feet: I i r f Water table depth SEPTIC,TANK ❑ Type/Mfg t t Capacity ? No. Compartments PKG. TREATMENT PLT. ❑ i F Method of Disposal Distance to nearest: Well # Foundation Property Line. LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: r Well i Foundation Property Line SEEPAGE PITS ❑ - Depth Size { Number SUMPS ❑ Distance to nearest: ; Well _ – " Fou dation"�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."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." The applicant ust call for all required inspections. Complete drawing onreverseside. Signed –Title:-- [..�T -- — Date: ` OR DEPAETMEIYT G$E_"ONLY Application Accepted by .G �=.� 11�� W►1 \`C.cMti/�� Date s '9_ Area Q Pit or Grout Inspection by Date Final Inspection by Dat�_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK C SH RECEIVED BY DATE pPERMIT"NO. + EH 13-241REV,V/85) �� ,� �� 2 O414 �� a _d 7 r EH 1426 ✓