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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x . (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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Loc I Health District. u i Job Address 15_3 c�• _! �rn'. City r�LLo_t 5iie PM r1,,�Gam.-'^/�r t��'G r✓�. 7 0- Owner's Name _ - / Address §. �r—�. - 7Ty-, Phone Contractor `A-P.__ Address License No. Phone f YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ F'. INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom F1%Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I: ❑ Irrigation ---Approx. Depffi`""❑ Eastern Surface Seal Installed by � Repair Work Done ❑ Type of Pump,) H.P. State Work Done Well Destruction 13 Well Diameter Sealing Sealing Material {top 501 Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is I available within 200 feet.) } Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a epth of 3 feet: J Water table depth SEPTIC TANK Type/Mfg J, fXMIEUethod rl o. Compartments PKG. TREATMENT PLT. ❑ i:— , ivii of Disposal Distance to nearest: ell Foundation__.,..._.__. Property Line er—iT have x (red ithout LEACHING LINE ❑ No. & Length of lines Work being corprilatod or 'fit 88 lze FILTER BED ❑ Distance to nearest: I- FouttProperty Line 01 rO11f111; :l f Te UIViSion I SEEPAGE PITS ❑ Depth fI Size 'Number SUMPS ❑ Distance to nearest: - (Nell' - 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,1 shall employ persons subject to workman's compensa- tion laws of California." '■ L The applicant must call for all required inspections. Complete drawing on reverse side. 9 Signed X �� '��_._ Title: Date: G FOR DEPARTMENT USE ONLY f Q41 Application Accepted by yy46. Date O I Area O Pit or Grout Inspection b i Date Final Inspection by Date r+ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ racy 835-63% j Applicant- Return ail copies to: Environ l ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J FEEAMOUNT DUE x� AMOUNT REMITTED OK RECEIVED BY DATE PERMIT"N0. 1NFO +EH 1324(REV.118 5Y 3 y EH td 28 /