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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ® � Telephone (209) 466-6781 +►�"�'` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AZ? (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address 5p. SAIiI,U,/, + _ City 5 Tk J4-) Lot Size PM Owner's Name t; OA-00'-"I ,2/Z��ddress _0d 6 SAi � ��./� Phone ��/�/' 3 Contractor Address 0 All, W,1 o L.t,J icense No.Zry_YV_5 .Phone TYPE OF WELL/PUMP: NEW WELL ❑ --- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUIMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/S MPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca'. Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy( ;,`' IType of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation { --Approx. Depth ❑ Eastern '$ Surface Seal Installed by Repair Work Done ❑ Type of Pump w,H.P.. State Work-Done Well Destruction I]. Well Diameter Sealing Material (top 50') Depth Fillet Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will seni9:. 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 1 s LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Z 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. r 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 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 must call for all r uired inspections, Complete drawing on reverse side. Signed X Title: Date: ' Fitt DEPARTMENT USE ONLY s Application Accepted by A9 lz"+l 11w a. �.A�.w,.n Mti Date Area_- 9 02 Pit or Grout Inspection by Date Final Inspection by Date 3 U Additional Comments: ✓ Q� 1 is Fis / L.r C�I l� r �� j��t� U� �J �"+ 3—Z v f-c ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638§45'& -kms r fv`31'�OrvV cP 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 CK 4 CASH RECEIVED BY DATE PERMIT"N0. + EH1 3-24 TREY. /a5) - G � EH 14-26 J��