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APPLICATION FOR PERMIT !, SAN JOAQUIN LOCAL HEALTH DISTRICT Yf 1601 E.e HAZELTON 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. /_70 •S+ -�� r� Joh Address City!;. Lot Size PM Owner's Name Cg ddress / _ /ti/, 5 Phone Contractor /v! _/�/ S Address_�� >y/ ! /� License No. ,46 Phone TYPE OF WELL/PUMP: NEW WELL_,51 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ' `�'SYs�EM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL .4 OTHER WELL PITS/SUMPS ._ f INTENDED"t7SE`- ""TYPE-OF-WEL-L PFfM'C M AREA CONSTRUCTI6rV SPECIFICATION 5, - # ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! 1 Domestic/Private Dia. of Well Casi g JVGravel Pack ❑ Tracy Type of Casing i !� Specifications s ❑ Public ❑ Ot er El Delta Depth of Grout Seal ` = r r✓�.S/h p Type of Grout ❑ Irrigation __ Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump U[3 H.P. , r State INork16one, Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 I' a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo'septic system permitted if putilic sewer is I available within'200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 6 r Character of soil to a depth of 3 feet: Water tabte depth SEPTIC TANK ❑ Type/Mf t g Capacity No. Compartments PKG. TREATMENT PLT. ❑ t •sal" t Method of t]isposal't�' Distance to nearest: Well Foundations''` 1-- - Property Line LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation,'. 't Property. Line SEEPAGE PITS ❑ Depth Size '', Number�, SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS � Property Line ❑ f� 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. ! 6 i , Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichthis permit is ued, I-eall 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." The applicant call or re i s 1 pections. Complete drawing on revers side. Signed Title: Date: `� FOR DEPARTMENT USE ONLY Q/ Appla;;; by \11�J{� s Date \��' C3 C] S �'f�i ,qR— Area .._ Pit on Date� Final Inspection Die 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT NO. �J c + EH13-24(REV.t/n5) EH 14-26 �U'�'