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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT fj�,�y. �{u►IQ�' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 No r 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. Job Address T—.1 (U 1�1) _ City., Gz f RJ Lot Size PM W; s� / Owner's Name f 1 i 11 Irl m .91 �Il�lc` y Address r;r `�y s4 c r.-7F Phone IZ7 p yr Contractor 57r- / Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL URE ELL OTHER WELL___ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS W ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty of Casing Specifications FI Public f] Other ❑ Delta Dept of Grout Seal _ Type of Grout I 1 Irrigation Approx. Depth l I Eastern Surface eal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material It X1111 Depth Filler Material (Below _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 RFPAIRlADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 206 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 to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth 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. 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 far required inspections Complete drawing on reverse side. . 0f Signed % � Title: t �i/Y�9��, Date: f�(W F DEPARTMENT USE ONLY C, r Application Accepted by z Date Area +f Pit or Grout Inspection by Date Final Inspection by Date S l d Additional Comments: ❑ Stk 466-6781 ❑ 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 95.201 INF AMOUNT DUE AMOUNT REMITTED REMITTED CK 4 CASH �RR�E]CEIVED BY DATE PERMIT'NO. + EH t3-241REV,tiies7 �(J V ��j, 00 le O /C� � a 9G� 90'd�9 EH to-2a I