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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6*_ PERMIT EXPIRES 1 YEAR,FROM .DATE ISSUEb;,,,,., (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. $� fin- Job Address Lot Size Vf Owner's Name /J'I? Address ^ _ Phone ..i r 'tits G , ©, Contractor's Name - --�_ License No. _-Phone TYPE OF WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUGTION_Q*,. j t' PUMP INST;4'LLATIOIV-0�.. SYSTEM REPAIR 11OTHER ❑J p DISTANCE TO NEAREST: SEPTIC., ANK SEWER LINES _ _DISP_OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHERIWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 1-1 Gravel Pack LJ Tracy e.,gfzcasin� `ti Specifications TI Public E) Other+ ❑ Delta Depth of Grout Seal Type pf Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ) Repair Work Done ❑ Type of Pump H P. State Work Done Well Destruction ❑ Well Diameter Sealing Materiel Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ i(No septic system permitted if public sewer is j , — -----=:available within 200 feet.► Installation will serve: Residence:)_ Commercial _ Other ; Number of living units: Number of bedrooms i 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg `1� Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 x t Method of DispLwl 3 'Vo well. t Foundation - _ Property Line Distance to nearest: �- LEACHING LINE A No. &'Length of lines M �{�� .k��+. � Tota{ length/size � `�-- :l .. r,, - � FILTER BED ❑ Distance toynearest: /Well 2MA F�ridation�� Property ii e 3 SEEPAGE PITS ❑ Depth Size' x ----fix Number;' �� . SUMPS ❑ Distance to nearest: Well: 'Foundation 'Property.-Line t ; 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 lawQof California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance 0�the work for which this-permit,iis issued,I steals 0-pIoy persons subject to workman's compensa- tion laws of California." wt I ' The applicant must call for all requird inspections. Complete drawing on reverse side. — � Signed X �1 —L%7- Title: Date: ae: ' .>� FOR DEPAR '-ENT USE ONLY Application Accepted by tcoe.�,.W.• &, -c � � Date! �' - ( Area Pit or Grout Inspection by Date Final Inspection by oLs as sf� Date 1 Additional Comments: _ ❑ Stk 466-5784 ❑'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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"N0. + EH 13-24(REV.1010 LAS + EH 1426 r C•'1 _ __ /11 b"-' _114C71 -