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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA SEP �ggg I Telephone (209) 466-6781 I: PERMIT EXPIRES 7 YEAR FROM DATE ISSUED HE/LIVI ' (Complete in Triplicate) �tv�PERM1ITI �CES I 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. �r^ Job Address J' City i of Size PM Owner's Name J3!l�" Address �G H'[ Phone 9S 2X-5`S' Contractor I ✓Gr1�ddress 59&s13,,R- SIO l--,-�10-�License No. S-2W t Phone :S/6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTEN DED-USE-_ — T—YPE-OF-WELL— =PROBLEMAREA:;WCONSTRUCTION SPECIFICATIONS` D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing febomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public IF] Other El Delta Depth of Grout Seal Type of Grout _ E I Irrigation E,Approx. Depth i I Eastern Surface Seal Installed by p - Repair Work Done ❑ Type of Pump SWb H.P. yL h,9 State Work Done �t+*+D ILPII�GLF+�ctYt� Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth SS Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is (-� available within 200 feet.) v Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Y f ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS D Distance to nearest: Well Foundation Property Line _ —DISPOSAL:PONDS'- _."'-❑ -r � - . ..�.� ..,� e-.��._ -x 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 i 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 a. employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature A. 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 calf for all quired 'nspections. Complete drawing on reverse side. i Qr Signed X Title: __. aura _ Date: w FOR DF.VARTMENT USE ONLY �AS�/ w� Application Accepted by Date 72/ Area Pit or Grout Inspection by bate _ Final Inspection by Date 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 95201 I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH13-24MEV.1/n5) ✓ �.f �,f'? �� 2 �� EH 14-26