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i APPLICATION FOR PERMIT 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. � Q/ / -1 n Jab Address T� [3 !V Ci �u Lot Size d`i© k1 PM fI � � Address 9 ��Z©Cfii Owner's Name ... _ Phone Contractor's Name License No. �"�`� Phone TYPE OF WELL/PUMP: NEWWELL`❑ WELL REPLACEMENT_Q DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I 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 ❑ Tracy Type of Casing'' � Specifications Tom' I ❑ Public ,k l A ;❑ Other ❑ Delta �A./" Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by E Q Repair Work Done ElType of Pump H.P. -4' -^� -State-Work-Done --=^-' 19-4 •/Nell Destruction',; .❑ Well Diameter Sealing Material (top 50') J I ,rte Depth.- `•o Filler Material (Below 501 TYPE OF SEPTIC WORK: -NEW INSTALLATION ❑ REPAIR/ADV1jQA64 DESTRUCTION ❑ No septic system permitted if public sewer is available-within 200 feet.) fp Installation will serve: Residence Commercial_ Other - Number of living units:� Number of bedrooms" Character of soil to a depth of 3 feet �s-' Water table depth r ?, SEPTIC TANK >< T e/Mf 5 ' Yp g Capac'ity CP®� — No. Compartments 21 PKG. TREATMENT PLT. ❑ f Method of Disposal R.FA"_-C Distance to nearest: Well I dW Foundation Property Line_ 'S-e*J LEACHING LINE No. & Length of lines l__� �0 1 L, Total length/size " Ai FILTER BED ❑ Distance to nearest: Well — Foundation Ai2 Property Line_-&O SEEPAGE PITS Depth C;LN'F. Size Number SUMPS ❑ Distance to nearest: Well /&D FoundationProperty Line ��' v, 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, tate laws, and rules and regulations of the San Joaquin Local Health District. , Home owner or licensed agent's signature certifies he followin 'F 9 !3" g: "I certify that in the performance of the work for which this permit is issued, I shall not employ any perso such manner as to be su ject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the folio in : "I certify that ih the pe rma ce of the work for whi �s p rmit is issued, I shall employ persons subject-to workman's compensa- tion laws of C for a." k The appli,a m for all re fired ins ,ns. Co plate drawing r rse aid�. Signed Title: Date: 'r r DEPARTMEN E' _ !Y Application Accepted-by ,_�� `' Date Area � � v Pitor Grout Inspection by �� Date Final Inspection+by ADate �6 - I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .r 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 CASH CK RECEIVED BY DATE PERMIT"N0. + EH 124 1EH 1 (REV.10183) 428