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i r� APPLICATION FOR PERMIT -rte " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address 9// � City ��C� Lot Size PM Owner's Name f e-+ LM6ZV0Addre. 9,;r ?L F-AV_1;A)I �Tf� J l� Phone Z Contractor 1 Address License No. (h e TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ _ _ OTHER C1 ' f _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N —,N TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Q Manteca. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private E7 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Ei. Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth E-fas'teffl Surface Seal Installed by Repair Work Dane ❑ Type of Pump . H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 I Depth Filler Material {Below 501 TYPE.OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION A(No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence 1 Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg ; Capacity No. CompartmentsPKG. TREATMENT PLT. 171 17 - Method of Disposal j Distance to nearest: Well Foundation Property Line / LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ; l 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. i I 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 Ilaws of California." The /;cant must call for all requir inspections. Complete drawing on reverse side. l y , Signa d _ Title: --- .-- - Date: ' FOR DEPARTMENT USE ONLY IM& ` Q Application Accepted by 4 Date ` > V Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: El Stk 466 6781 • Lodi 369-3621 anti#ca 'BM71044 \—O �rac� 835 B385" " - Applicant r,. all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O..Box 2009,_Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K INFO H RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.i/as) fi �� ,1�•�,� .�`,�3 EH 1428 �/JJ L X