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F i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f / 1601 E. HAZEL T ON AVE., STOCKTON, CA �• y V s Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 wi San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health Distric f Job Address 93 l -S f City ` Lot Size + / .3, �2— PM Owner's Name s ✓ Address / �D Phone Contractor 4 Address l4 2-4 a��o� S� License No. �Phone TYPE OF W LLlPUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAI ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM ARE CONST CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D Manteca ` Dia. Well Excavation Dia. of Well Casing e ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e of Ca ' Specifications 17 Public ❑ Other Ll Delta epth of Grout Sea Type of Grout -I i Irrigation Approxi Depth I I_Eastern Sudace-Seal Installed by Repair Work Done ❑ Type of Pump H, State Work Done ► 1 Well Destruction ❑ Well Diameter Sealing Material (top 50 V Depth Filter Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION 1 I DESTRUCTIO INo septic system permitted if public sewer is �} vailable within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Nu 6 r of bedrooms x. Character of soil to a depth of 3 feet: = ---Water table depth SEPTIC TANK ❑ Type/Mfg Capacity---L. No. Compartments PKG. TREATMENT PLT. ❑ IV Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth J Size °' Number.- SUMPS ❑ 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 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." Contractors hiring or subcontracting 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 Califon)- ,%r .The applicant mu call for all wired ' t ns. Complete drawing on reverse side. igned X Title: tm -3/2 Date: r 4��OR DEPARTMENT USE ONLYApplication Accepted by em _ Date Area Pit or Grout Inspection by Da Final Inspection by Date Additional Comments: I t'/f! 04 -S � r 1►!k_ �&2 2-Z 0 Silk 466-6781 ❑ Lodi 369-3621 ' 0 Manteca 823-7104 Cl Tracy 835-6385 . Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE `p INFO AMDUNTa DUE AMOUNT �R/E�MITTED CK 49 ASH RECEIVED BY DATE PERMIT' NO. +.EH t324(REV.1iR5) SruV � `V