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j� APPLICATION FOR PERMIT ii SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. •o w ,I Job Address City Lot Size PM �' � Owner's Name Addressy� ,of w. & Qom- � - - Phone Contract Address I[ % FJ�X�47 e License No�3`-�Z-Z!(f Phone `� `Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑' = PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑I `I '., DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrials ❑ Open Bo{tam ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j -: -.., r „ ❑ Domestic/-Private 11 Gravel Pack LJ Tracy Type of Casing Specifications c l!t l'1 Public �- v❑-at (it ' •� ❑ Delta Depth of Grout Seal _ Type of Grout � I I Irrigation �'I..Approx. Depth .\i I Eastern •'Surface Seal installed by '. n Repair Work Done ED, Type of Pump H.P. "I State Work Done _ Well Destruction t`"`❑. Well-Diameter. '' - Sealing Material stop 501 Depth _ Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTAL17ATI.ON I/T REPAIR1ADDITION-i I " DESTRUCTION i-1 (No septic system permitted if public sewer is j available within 200 feet.1 Installation will serve: Residence_ Commercial_ Other . t Number of living units:'O.--Number of be'f oo!ns Character of soil to a depth of of 3 feet: Water table depth SEPTIC TANK P type/Mfg Capacity d No. Compartments PKG. TREATMENT PLT. O ;� r ` -'? ._ l _ Method of Dispo al Distance to nearest: Well Fouridation Property Line 25 i �=' ! A LEACHING LINE No. & Length of lines ` Tofal lengthlsize FILTER BED ❑ Distance to nearest: ' Well Foundation— Property Line I SEEPAGE PITS i`I Depth �r� Size '� © Number SUMPS / #*r-,bistance to nearest: Well 00 Foundation /fJ - Property Line�� DISPOSAL PONDS rr` 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 o�the San Joaquin Local Health District. Home owner or Iicensed-agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shatl 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, I shall employ persons subject to workman's compensa- tion laws of California." Ik The applicant call for all re uir ins ctions. Complete drawing on reverse side. �r Signed X Title: Date: /4✓ FOR DE ARTMENT USE ONLY Applicat' n AciceeJ1ptadd by Date r yAraay�'� `} /� L� I it�SIhe�Ctidn by Date// Final Inspection by Date `_ f� r.- - - ..--_... - - •• - r Additional'Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104'w 4 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Parini Services 1601 E. Hazelton Ave; P:O.'Box 2009, Stk., CA 95201 IEEEO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY If DATE PERMIT'NO. + EH 13-21 IN .1/x51 7��0 V - / �78�1 EH 11-28 F I IE