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APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA —Telephone (209) 466-6781 ;PERMIT EXPIRES 1 YEAR fROM DATE.ISSUED �� , , 4.= i (Complete in Triplicate) t. ., ii;3�ir1 tl y 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'" -41 -,y - '�- - Y d ,Y'.t : • ! . ".' y' .-+Iy,G�.k'.°�i;V �� �,• " `' Lot Size Lh PM Job Address • }City Owner's Name-"►✓_ Address Phone `Contractor t ess License flo. � 6 Phonef — TYPE OF WELL/PUMP: ` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4N ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx.. Depth ❑ Eastern Surface-Seal Installed by Repair Work Done LlType of Pump H.P. State Work Dona i I Well Destruction ❑ Well Diameter Sealing Material (tap 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .. available within 200 feet.) II Installation will serve: Residence Commercial Other n Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:{ Water table depth /0 ' ye SEPTIC TANKy# Type/Mfg Capacity No. Compartments " ' PKC, TREATMENT PLT. ❑ Method of Disposal Distance 10 nearest: Well.1004 Foundation ry � Propeity Line " �'�' Total length/size} LEACHING LINE No. & Length of lines ^^ r ' "� Foundation r� �� Prop" Line r L FILTER BED ❑ Distance to nearest: Well .— Vim- p tt51 � 15— SEEPAGE PITS ❑ Depth k2 Size 3 Number ` # !Mp.�p� SUMPS ❑ Distance to.nearest: Well� Foundfation s Property tine, O" DISPOSAL PONDS ❑ '` � I hereby certify that I have prepared this application and that the work will be done in acgoidance 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'whicch this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contfactor 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- I e '. tion laws of California." _ ti� J Thead pplica t must call for all required inspections. Complete drawing on reverse side. Signet }��'� Title: Dater t r FOR DEPARTMENT USE ONLY Application Accepted by �"� Date (-b� Area Date (a- Q-`I Final Inspection by�� - Date Pito Grout Inspection by - . i J t 4 Additional Comments: j ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca .823-7104 . ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave,, P.O. Box 2009, Stk., CA 95MI FEE AMOUNT DUE AMOUNT REMITTED CK a � RECENED-BY DATE PERMIT'NO. INFO c CASH + EH1324 CREv:1/95) '4`., ,\'y^ ".s - rjr' A, —57 EH 14-26 _7_6, o- % .- f