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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f` 1/to u 1601 E. HAZE.T ON AVE., STOCKTON, CAy ( �9 i Telephone 12091 466-6781 pj !� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fir+- . r (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 applic Applica ation is compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin made F Local Health District. City Lot Size '527X!-Cfy PM Job Address �l6 / Address Phone Owner's Name +j°af/ License No. Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL F7 WELL REPLACEMENT ElDESTRUCTION L] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL.. PROBLEM AREA " CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca. Dia. of Well Excavation Specifications EJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,..K Type of Grout ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r (5Irrigation YP I J�lpprox. Depth L1 Eastern ; Surface Seal Installed by H.P. State Work Done Repair Work Done ❑ Type of Pump , + Well Destruction ❑ Well Diameter Sealing Material stop 501 ` k Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION)kiNailableo septi cyst m Perrfeetitted if public sewer is '+ Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity) 0 No. Compartments SEPTIC TANK ❑ Type/Mfg V Method of Disposal PKG. TREATMENT PLT. ❑ ` Distance'to nearest:: Well Foundation Property Line , l LEACHING LINE ❑ No. 8 Length of lines. Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 4 ` 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. following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the 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 personfollowiin u certify that si. the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- i tion laws of California." The applican st call for all require i spections. C mplete drawing on reverse side. i Title: Date: Signed t 1.Z ti4– H\l. FOR DEPARTMENT USE ONLY �� r Area Application Accepted by F��pate n y Date Pit or Grout Inspection by Additional Comments: 71- 7-1-4 L 1 Additional 46Com ❑ Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy 835-6385 ' A.1 c P( ( pplicant- Re rn all opies to: E vir mental Health Pe ervices 1601 E. Hazelton Ave., P.O. Box Stk., CA 95201 3 r RECEIVED BY DATE PERMIT NO. tv� FEE AMOUNT DUE AMOUNT REMITTED CASH INFO _yQ 3 ISS/ `'� ,ZJ IS-1-7 a EH 13-24{REV.5/n 5] "� �� O� 4,3S—d—' �/��_ `�" 1 /" v � D EH 14-26 u