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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1; PERMIT EXPIRES 11'YEAR FROM DATE ISSUED . (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/of 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. 5 q �• UiaL Job Address -5 Gity �j Lot Size_so K 120 PM JCl� Y1 S *rZ *7960 . Owner's Name �• !� f� � � Address Phone Contractor P�'k' I Address License No. Phone TYPE OF WELL/PUMP: i _ NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ JSYSTEM REPAIR❑'" OTHER ❑ DISTANCE TO NEAREST: SEPT SEWER LINES DISPOSAL FLO.- PROP. LINE FOUNDATION AGRI LL OTHER WELL f PITS/SUMPS µ INTENDED USE TYPE OF WELL PROBLEM AREA "CONSTRUCTION ATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p tions F-1 Public n Other ❑ Delta `Depth of Grout Seal Type of Gro. I i Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter x Sealing Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION" (No septic system permitted if public sewer is I r vailable within 200 feet.) Installation will serve: 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 rto nearest: Well Foundation Property Line i f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property"Line SEEPAGE PITS 11 Depth Size Number SUMPS C1 Distance Ito nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 6 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. Homeowner 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 certifythat 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." h The applicant must call for all regmtM inspections. Complete drawing on reverse side. Date: �-2 .� Signed Title: -_ /l/>✓uL ....r,.,.,.,TFOR.DEP RTMENT E-ONL-Y G /� Application Accepted y i' Date D rea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE AMOUNT DUE AMOUNT REMITTED C5H RECEIVED BY DATE PERMIT'NO. E INFO ( nye + EH 1321[HEV.1?n 57 EH 11-213 -C�' c73 tiK t 3 +U v 1 �„ T�((lJy � `