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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I (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. NAL City _ Jab Address i[�t_i'r�._.T117 � L A�21�J'7C3CTalJ�1 1 RAGS/ Lot Size PM Owner's Name L4Address "V-46-�Ft� B Phone-h5i2J�..y' 1 ?cm �! Contractor Address _ License No. TYPE OF WELL/PUMP: �L�—� E iV REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ CSYSTEM REPAIR ❑ OTHER �Cpl�11CAL1t.IC� i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A- 8 tom_ Dia. of Well Casing 5- D ❑ Domestic/Private ❑ Gravel Pack /14 Tracy Type ofasing Specifications i M Public 171 Other ❑ Delta Depth off1 Sb-_4C]4T Type of Grout I I Irrigation ___,.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ; Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . PKG.:TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 5 SEEPAGE PITS l I Depth 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: "1 certify that in the performance of the work for which this permit is issued, I shalt 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 i 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." i d The applicant mus all f I req inspections. Complete drawing on reverse side. t Signed Title: �idf F FitChl a�1Ef� Date: FO DEPARTMfN7 USE ONLY _ Applic ion Accepted by Dat �Q Area Pit r Grout In ction b}r _' �� Datl6 Final Inspection by _ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 1 369-3621. ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 85201 INFO A�M�/O/U/yNT DUE AMOUNT REMITTED AFEE SH RECEIVED BY DATE PERMIT'NO. EH 00 13-24{REV.i/H51 T + T 9i1 1Or EH 14-29 V J f 1 ll q