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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l •. 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 Nd. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address City "�i � Lot Size �as5 PM � � Owner's Nameo� Address Lt1._ _ ,-�� Phone'�� , 4��Contract r 6 Addressy, es mo o & License NoM Ez Z� _Phone a+S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4"- FOUNDATION---— - AGRICULTURE-WELL' ` OTHER WELL PITS/SUMPS' = INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'7 Public Ci Other ❑ Delta Depth of Grout Seal Type of Grout 41_ I I Irrigation --Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ W Well Destruction ❑ Well Diameter, Sealing Material ftop 501 Depth `` ' r Material-(Below 50') TYPE.OF SEPTIC.WORK: NEW INSTALLATION l,l ..REP.AIR/ DDITION lDESTRUCTION l.I..(No septic system permitted if public sewer is i •/ available within 200 feet.) C' Installation will serve: Residence_ Commercial Other (Q Number of living units/ Number e roo s Character of soil to a_,depih of 3 feet: Water table depth SEPTIC TANK i Type/Mfg Capacity DCS No. Compartments PKG. TREATMENT PLT. ❑ r=-^ _ _ r Method of Disposal Distance to nearest:; Wel6p� Foundation h� Property Line t� f LEACHING LINE No. & Length of line's Total length/size r FILTER BED - �+ � ❑ Distance to nearest: Well,` Foundation Property Line c_S ry ,.• I- _ SEEPAGE PITS d^ Depth f Size (Number It SUMPS N:;- / Ll_ Distance to;nearestrl; Well Foundation Property Line 1.5 DISPOSAL PONDS ❑ - .} t.1 --_�_. fff hereby cartify-that 1.1 -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 esibnature 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:'1-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." 1 s Thea applicant t call fo a e "red ins pp q pections. Complete drawing on reverse std � •iv'f.< ` +-`'�� `s Signed X r Title:"� � :' '- `' ^.' , -�" Date: FOR DEPARTMENT U5E ONL'r�" � r Application Accepted by-J-i^ tx' Date Area Pit or Grout fnspection-by— Date Final Inspection by Date Additional Comments: �-' f a � 611S�-d D ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 If Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT NO. t3-24-.IREV,r/K 51 EH 14-26 t