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fit APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEP)LTH 'DISTJiICT 1601 E. HAZEL i ON AVE., TOCKTON;CA w yrs Telephone (209) 466-6781 =, PERMIT EXPIRES TYEAR FROM DATE ISSUED, ' (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 'pl cafian is made in compliance with San Joaquin County Ordinance No.549 for.sewage or No. 1862 for well/pump and the Ru16 and Regulations of tf?e..5ari`Joaquin local Health District. }i Job Address V t, City Lot Size PM Owner's Name Address fdo 2e Phone i ^�3g Contractor Address 2 S3 License No.��Phone_ TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT (7 DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST:'SEPTIC TANi . SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' 'CONSTRUCTION SP� ❑ Industrial fl Open Bottom [_1 Mantecaa `Excavation Dia. of Well Casing t .•❑ Domestic/Private ❑ Gravel Pack' ❑ Tra Type of Casing Specifications M Public ^❑ Other ! Delta Depth of Grout�Seal .Type of Grout _ t I ]'Irrigation _..Aper ept?r' •;I;I Eastern Surface Seal installed by - 1 Repair Work Done ❑ Type of Pump '' H.P. State Work Done_ Well Destruction , ❑ Well Diameter Sealing Material Itop.50'.)---- Depth —Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDiTION I I DESTRUCTIOVXINo septic system permitted if public sewer is J i available within 200 feet.) r 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 l SEPTIC TANK l ❑ Type/Mfg I y Capacity No. Compartments i PKG. TREATMEN-QLT. ❑ Method of Disposal J _ a Distance to nearest: Well � Foundation Property Line LEACHING LINE ❑., No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I1 Depth rl Size Number SUMPS ❑ Distance to nearest: Well 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,I shall employ persons subject to workman's compensa- tion laws of California. I .The applicant ust call for all requi ed inspections: Compiete drawing on'reverse side. " Signed Title; C �lr� BGG / Date: T USE ONLY, 1 �] � ,� ! Application Accepted by DateAra Ar Pit or Grout Inspection by r D Final Inspection by Date' ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1335-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j ? i FEE AMOUNT DUE AMOUNT REMITTED —CASH RECEIVED BY DATE PERMIT'NO. I INFO 2 + EH 13-24 1REV,1/9 51 l5 a� �� 1.��. ,{7-0 (� .