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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'I4EALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'' (Complete,n Tri plicate) 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 Ryles and Regulations of the San Joaquin Local Health District. . Job Address : '� �ih { [�' "; CityLot Size PM Owner's Nam -e1&5a 3rd -Address r Phone Contractor r Address1[7,7—7 ,f4ZV 9"*cense No. /�l✓� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR a OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FJ_D. PROP. LINE_ 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 J21-Domestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing Specifications 1 ❑ Public ❑ Other ❑ Delta Depth'of Grout Seal Type of Grout t ❑ Irrigation ---Approx. Depth ; Eastern Surface Seal Installed by Repair Work Done ,8' Type of Pump ' H.P. _1 _�: State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (gelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑� REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve:--Residence= Co erciaf_^Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' R W ter table depth SEPTIC TANK EJ- Type/Mfg t ~ Capacity No. Compartments PKG. TREATMENT PLT. ❑ } e Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 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 ❑ 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 j rules and regulations of the San Joaquin Local Health District. 11 . . - 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." Contractors 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 laws of California.' The applicant ust c II "l required inspections. Complete drawing on r se side_ y t+ Signed I, �v /l` -y. Title: Date: FOR DEPARTMENT USE ONLY +" Application Accepted by �/ rri Date 2 Area Pit or Grout Inspection by Date �'"� Final Inspection by Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED. CA RECEIVED BY F DATE PERMIT`N0. + EH 14-26IREv. /aslits ` C.