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X10. '7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON,AVE„ STOCKTON, CA -Telephone-(266Y,466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t y (Complete in Triplicate) DtisR , I s 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.Rtlles and Regulations of the San Joaquin { Local Health District. Job Address 1 l "7 A.p11 ,QS , City rw PM Owner's ame 1A L1/id-• ��a i Address17 7- Phone _ r V idense No. �2 V 4 Contractor __ . -r : i ress ane S TYPE OF WELL/PUMP:` . + NEW I I ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ /PUf P INSTALLATION El I,-' SYSTEM REPAIR I , OTHER ❑ DISTANCE TO NEAREST:OSEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE ` FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca g Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type ype of Grout' ❑ Irrigation _--Approx. Depth ❑ astern SA ee Seal Installed by Repair Work Done f�Type of Pump H.P.' State Work-Done Well Destruction El Well Diameter Sealing Material (top 50'1 Depth I Filler Material 18elow 501 — t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Ne septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number,of bedrooms 3 i Character of soil to a depth of 3 feet, Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity i No. Compartments PKG- TREATMENT PLT. ❑ # I Method of Disposal Distance to nearest: -Well Foundation Proorty3Line LEACHING LINE ❑ No. & Length of Unes _-__ f 1 _ Total length/size FILTER BED ❑ Distance to nearest: Welly F_oundat+on Property Line SEEPAGE PITS '❑ Depth Size k T *_ M_ Number SUMPS ❑ Distance to nearest: WellFoundation Property Line DISPOSAL PONDS ❑ F -1-hereby certify that I have prepared this application and that the"work will be do a in accordance with.San Joaquin county ordinances, state laws, and rules and re Ions of t e Joaquin Local Health District. # r Home ow r or licensed agent's s ature certifies the following:€"I certify that in the performance of the work for which this permit is issued, I shall not `A employ y person in such manner as o become subject to orkman's co nsation laws of California."Contractor's hiring or sub-contracting signature certifies he-following-l-certify_that,in. rformance of a o`rk f icH his permi shall employ persons subject to workman's compensa �S tion Is of California. The apple ant-must call r all inspec ti reverse de. \ Signed d` pate: FOR EPARTME T USE ONLY .. �- Application Accepted by Dat �� Area Pit or Grout Inspection by 6ate Final Inspectionby Date qlfff Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .; 4. f I w f INFO CK AMOUNT DUE.. AMOUNT REMITTED CASH RECEIVED BY DATE _ PERMIT"NO. + EH 1324(REV.7to6) '01n: EH 1426 ' -9, oA ' G .