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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. ey- c� aJ. --A- Job nn Address - IRI City 1ka 10 Lot.Size PM Owner's Name __VS ell I a F lJ��Y Address Phone + , Contractor I r" r Xl _ f t ! �y�SSt1 P� Address License No. hone r j TYPE OF WELL/PUMP:; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El 1 ..� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTITANK 'SEWER,LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED.USE 6TYPE OF WELL PROBLEM ARB� CONSTRUCTION SPECIFICA1-10N ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing ❑ Domestic/Private ID Gravel Pack El Tracy Type of Casing Specifications Cl Public (=] Other Cl Delta Deplih of Grout Seal Type of Grout _ 13 Irrigation --Approx. Depth l I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction __171 Well Diameter Sealing Material {top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIONV,�-DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resideri-Ce-Z Commercial_ Other Number of living units:_�_ Number of bedrooms �. Character of soil to a depth of 3 feet: -� n Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS %,_6"Distance to nearest: Well _ Foundation �1_4 t Property Line .3 5 DISPOSAL PONDS ❑ 2 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 ::i 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." Contractor's hiring or sub-contracting signature certifies the fallowing:"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 must c II for all r wired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date �L. Area Pit or Grout Inspection by Date Final Inspection by Date O, Additional Comments: 1K ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. +.EH 1 2 3-24 IREV.t i n sy R I g- � EH 14-28 !- ,S