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Ft • I j APPLICATION-FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 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. Clty 4G Lot Size PM Job Address ` Owner's Name _ �G'��jJ' `{ Address • � C' *+ Phone v 3 C `r6 Contractor t Address Vo 1504 ~ License No. Phone ' S TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ X SYSTEM REPAIR ❑ \OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK ^X SEWER LINES �DISPOSAL.FLD. PROP. LINE _ FOUNDATION_ AGRICULTURE WELL OTHER WELI`. _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA'. CONSTRUCTION SPECIFICATIONS �'+� ❑ Industrial ❑ Open Bottom •❑ Manteca Dia. of Well Excavation '_ Dia. of'Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TracyType of Casirig ` Specifications Fl Public t ❑ Other ❑ Delta Depth of Grout Seal Type of Grout, r I I Irrigation _Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done LDType of Pump " H.P. \State.Work Donet -- r •+ Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth it Filler Material IBelow 50,IX TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I ,DESTRUCTION I 1 iNo septic system permitted if public sb wer is available within 200 feet.) i Installation will serv-e`Residence'f✓/Commercial Other' r r Number of living units: _L_ Number of bedr oms r r Character of soil to a depth of 3 feet: ,uQ'ion&, t l "'_ Water table depth SEPTIC TANK Type/Mfg / LlA2,1'C1-- Capacity— No. Compartments PKG. TREATMENT PLT. ❑ t .,, *Method of'Dispos al I Y� Distan#e to nearest: Well�) Foundation Property ?i6e -7 _ LEACHING LINE No. &Length,olines iQ Total length/size# f FILTER BED EI Distance to nearest: Well Foundation �/� Property'Line 3 - SEEPAGE PITS I I Depth Size Number 1' SUMPS L�/�Distance to nearest: Well Foundation Property dine r, t DISPOSAL PONDS ❑` € - I U 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 foaquin Local Health District. f f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the Work for which this permit is isstied, I shall not i 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 workmari's compensa- tion laws of California." 1i ; The applicant must call for-all re uired'inspections:•Complete-drawing on reverse side: Signed X Title: / Date: Idw0 f F FOR ZDEARTMEN USENLYV��/ f Application Accepted by Date Area G Pit or Grout Inspection by ° Da a Final In pection by Date-4 �a O �f, Additional Comments: -'-❑'Stk '466-6781- -` ❑ Lodi 369-3621—❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave:; P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY Y.DATEa PERMIT"NO. INFO 4 ` r EH 43-24{REV.t/n 51 O - d•—� ` L - EH 14.28