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I ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES TYEAR FROM DATE ISSUED I (Complete in Triplicate) ApPIrcation 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. i1 !!! �.r��[7 S e�j v L rE.' �+"�- City YAG' Lot Size PM IlJob Address + I�i .117V Owner's Name .('�tzt/ttYf �''L�SS � Address O d.,7't' ge Phone Contractor, SOA' Address 0�.7 Lbw IP114 deS7O License No. 'y"'$9I Phone��+T"y•2!-I' 1"ISTA TYPE OFWELL/PUMP: NEW WELL ❑ WELL EPLACEMENT ❑ DESTRUCTION ❑PUMP INSTALLATION ❑ STEM REPAIR © OTHER ❑NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F) Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout i I I Irrigation _Approx. Depth t 1 Eastern Surface Seal installed by - J Repair Work Done ❑ Type of Pump H.P. State Work Done _ %J) Well Destruction ❑ Well Diameter Sealing Material Stop 50'i 0 Depth Filler Material (Below 501 $ ,TYPE OF SEPTIC WORK: NEW INSTALLATION/r REPAIRIADDITION 1 1 DESTRUCTION l I aNailabptic systemithin permitted if public sewer isvle {} LAInstallation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: 11�A✓ �oesy�t Water table depth SEPTIC TANK Wr Type/Mfg �y CAST Capacity -.-- No. Compartments �+ PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well ace Foundation �� P Property Line Yc LEACHING LINE No. & Length of lines/ �00 Total length/size FILTER BED ❑ Distance to nearest: Well 3'e" Foundation 1S0 Property Line .-_— I SEEPAGE PITS I 1 Depth size 6•'rd' O IF Number SUMPS 1( Distance to nearest: Well Foundation Property Line _ I DISPOSAL PONDS ❑ (,hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health District. fHome 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 E. 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." Theapplicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: DEPARTMENT USE ONLY I Date Area I Application Accepted by I . Date Pit or Grout Inspection by D e Final inspection by L Lam— 1 i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy. 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I I PEE AMOUNT DUE AMOUNT REMITTED 5:!1s) CASH RECEIVED BY DATE PER__7MIT NO. i INFO + E 113-24(REV. 5) ;' �� '` EH 1 4-2a