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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,a X4q 1601 E. HAZE.T ON AVE., STOCKTON, CA 0�"" Telephone (209) 466-6781 ('0'. rI 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. t: FJo,bddress City Lot Size e PM f 's Name �1-e V`\ O&)� A�j Address �, p Phone2,69 `'79' Zt{76 f 09 ctor t Address 2 3IT License No.Y 255Phone V6— _7 TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTi N — PUMP INSTALLATION ❑ SYSTEM REPAIR El IPRLD,10 DISTANCE TO NEAREST: SEPTIC TANK'— SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS ` 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other F1 Delta Depth of Grout Seat Type of Grout — I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump . H, State Workbone_ s V Well Destruction ❑ Well Diameter Sealing Material {;op 50') .•M - Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION I I DESTRUCTION i I (No.septic system permitted it public sewer is available within 200 feet.) 4 Installation iwill serve: Residence_ Commercial_ Other } 4 Number ofrliving units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK E3 T e/Mf YP g Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of..Disposal Distance to nearest: Well Foundation Property Line S"— LEACHING LINE ❑ No. & Length of lines,,' '_I_ , x w Total length/size FILTER BED ❑ Distance to nearest: Well Foundation �.f Property Line { s I � SEEPAGE PITS I 1 Depthsize ' Number SUMPS 'L� Distance to nearest: Well Foundation • Property Line DISPOSAL PONDS ❑ I r 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. t Home owner or licensed agent's9 signature following: "I certify that in the performance of the work for which this permit is issued, I shall no dertifies the follin ttes " employ any person in such manner as to becomesubjectsubject 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, I shall employ persons subject to workman's compensa tion laws of California." # 1 The apple must call for II req it d inspections. Complete drawing on reverse side. 4 Signed Title: Date: _ _ ?6— I � k FO EP�NT NLY Application Accepted by Date ,t ��J (�\ Area Pit or Grout Inspection by Data Final Inspection by k y�li Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to:-I=nvironmentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE- ' AMOUNT REMITTED-INFO �' 1. '-CX-SH RECEIVED BY DATE PERMIT'NO, H 13:24/REV.1/951 EH 14-26