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7 APPLICATION FOR PERMIT c SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA t Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s 4; (Compiete in Triplicate);$1' f• e Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs 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 ( .YEI T' ' ,ST' City t� Lot Size 15-0 PM .r "Oririer's Name Address Phone ° Contractor. �� Address �} St7 t ' License No.,��_Phone4lo��- 07 TYPE OF WELL/PUMP: ;' NEW WELL'.❑;�x WELL'REPLACEfiAENTCp:-'%-,z._ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL_FLD. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial L3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout. ❑ Irrigation Approx. Depth_./D Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. s t 31 State Work Done Well Destruction ❑ W,11'Diameter Sealing Material (top 50') $ `` Depth Filler Mtj aterial l8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION ■ DESTRUCTION ❑ (No septic system permitted if public sewer is 0—aitable-within200 feet.) Installation will serve: Residence Commercial_ Other F 10 Number of living units: _.-_L-� Number of bedrooms Character of soil to a depth of 3 feet: ArD62 Water table deptfr SEPTIC TANK ❑ Type/Mfg wed w Q [ +t _ Capacity 6B 0 No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal L L !T Distance to nearest: - Well Fpundation I0, � Property Line dQ_ LEACHING LINE ❑ No. & Length of lines 1� r� ToWDength/size FILTER BED ❑ Distance to nearest: Well Foundation €' Property Line # SEEPAGE PITS ■ Depth Size f11 Number 3 SUMPS ❑ Di ~ stance to nearest: Well - Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that 1 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. Home owner or licensed agent's-sig nature certifies the following: "I certifythat 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 law's of California."Contractors hiring or sub-contracting signatu , re certifies the following:""I certify that in the performance of the work for which this permit is issuedI shall employ persons subject to workman's compensa- tion laws of California." 1 � -41, The applicant must call for all required inspections. Complete drawing on reverse side. ; ILJ i' Signed Title: 1 Date: 1'0,3-L� + l FOR DEPARTMENT USE ONLY } 4 Application Accepted byDate r Area 021— I " Pit or Grout Inspection b �. 7) 4VFi.,I p y � Date Inspection by Date} Z' Additional Comments: ❑ Stk 466-6781 ❑ Lodi ,j 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 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO CASH '+'EH 13-241REV.I H5) �' l EH 14-28 `70 •7.Q ,�,e Slo^b� .