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r APPLICATION.FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE4TON 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 j 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 i Local Health District. Job Address i.� w' City 6SC,' j Lot Size PM F IC1N �e_- i D � Phone 9 .Q a Owner' ame L Address !aW� 03 �� (j39 V6 Contractorvlg� �/ Lo Addre License No. Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ _ PUMP INSTALLATION-/— - -4 SYSTEM REPAIR ❑ OT ER ❑ _ � �� DISTANCE TO NEAREST: SEPTIC TANK �- SEWER LINES DISPOSAL FLD. _ PROP, LINE r ' ,' FOUNDATION -f' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.`of Well Excaav�a�ti+on� Dia. of Well Casing fD �. Domestic/Private Gravel Pack ❑ Tracy Type of CasingTJ�tiif Specifications ❑ Public 171 Other El Delta Depth of Grout Seal Type of Grout L-1Irrigation --Approx. Depth ElEastern Surface Seal Installed by t E Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diame Sealing Material [top 50'1 'Id - epth Filler Material (Below 50'1 I'I T PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is available within 200 feet.) ` b_ lnstallatior3bvi erve: Residence_ Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 r table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments. I PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well ndation Property Line LEACHING LINE ❑ No. & Length s th/size FILTER BED ❑ Dist o nearest; Well Foundation Prope e SEEPAGE PITS ❑ Depth Size Number - """"`- " ySUMPS 171Distan6e to nearest: Well Foundation T Property Line's 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 rules and regulations of the San Joaquin Local Health District. 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."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must.'" "Legyired inspections. Complete drawing on reverse side. i Signed X Title: Date: T-30 R UPARTMENT USE ONLY fl" Date Area Application Accepted by J Pit or Grout Inspection by ate I�7(J� Final Inspection by Date r6 I Additional Comm*, - ( 0 r� r SS P/fl ffaL F Additional Comm*❑ Stk 466-6781 ElLodi 369-3621 Mace 823823-71� _ ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O.ox Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO I _ + EH 1324(REV.7/65) EH 14-26 ccc i