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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON�AVE., STOCKTON, CA Telephone (209) 466-6781 AUG PERMIT EXPIRES 1-YEAR FROM DATE ISSUED HEALTH (Complete in Triplicate) �NvL1 IMT•IT/ ` SERACE.S HERM 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. �f 4 Job Address [ rq�o VU Cit ize PM Owner's NameV Address 7 9U Phone `�' " �J� r Contract ddressPC 1310 !Yp x Cl License No,l Z 3 �3 Phone TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL i OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCTIdN SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications M Public F] Other n Delta Depth of Grout`Seal Type of Grout _ I I Irrigation _..Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done {Type of Pump S rIV iGt .P. state Work Done Q Well Destruction ❑ Well Diameter Sealing Material atop 50'I' Depth Filler.Material (Below 50'1( lJ TYPE OF SEPTIC-WORK: .NEW INSTAL'L:ATION I 1 REPAlWAODITION 1:1...-.DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) •Instaliation will..serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: �_-_ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation F '' Property Line . LEACHING LINE ❑ No. & Length of lines r`��Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS l I Depth Size Number SUMPS L1 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 ir1 accordance with San Joaquin county ordinances, state laws, and rules and regulations of an Joaquin Local Health District. Home owner or rrelsed agent's nature certifies the foil g: "I certify that in the performance of the work for which this permit is issued, I shall not employ any p on in such manner s to becom su ec o w kman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the Ilowing; "I certify th in tha of c of th ork for which this it is issued, I shall employ persons subject to workman's compensa- tion laws o California." r The applic nt must call for squired ns plete dr wing on ev si e. J Signed X _ _ - - _ — -- ills: -- -- •~-Date:' FOR (DEPARTMENT USE ONLY r�� Application Accepted by - Date- 9-7 7�r� — Area Pit or Grout Inspection by Date Final Inspection by ZiAlr22i Date/&44_8V Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 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 ASH CK RECEIVED BY /DATE PERMIT NO. r.EH 13-24 TREY,i/n 51 EH 1428 [J