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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES TYEAR 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 9 6 11&_�)Y I. City Lot Size PM e&ZnOwner's Name �QA1 � Address Phone d� Contractor&�ITW t-5b,05 Address � �� '�'� License No. Phone ! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION-0 ~ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � .. OTHER ❑ t i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. , - PROP. LINE FOUNDATION AGRICULTURE WELL,� OTHER WELL 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 ❑ Gravel Pack� --I—]-Tracy Type of Casing Specifications ❑ Public F1 Other----- n Delta Depth of Grout Seal' ' TVpe.dIf Grout I I Irrigaiion _Approx. Depth-- I 1 Eastern � Surface Seal Installed by Repair Work Done-•- ❑ Type of Pump H.P. State Work Done✓ Well'pestruction ❑ Well Diameter ling Material Itop 50'1 s Depth— T seaFiller Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {:I REPAIR/ADDITION DESTRUCTION i I (No septic-system permitted if public sewer is, �- available within 200 feet.] L Installation will serve: _Residence Commercial Other- Number therNumber of living units: Number of bedrooms ✓ Character of-soil to a depth of 3 feet: _Water table depth n SEPTIC S-ANK ❑ Type/Mfg Capacity No. Compartments r t"11 PKO. TREATMENT PLT. EI Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE 1 No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well �� Foundation ley- ' Property Line 10 ' r SEEPAGE PITS Depth _Size Number SUMPS CI Distance to nearest: Well :V i_ Foundation /4Z!/ Property Line DISPOSAL PONDS t❑ 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 plainer 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." R t3 The applicant m st call for all required inspections. Complete drawing on reverse side. r/ t+ r Signed X i s Title: Date: �., FOR DEPARTMENT USE ONLY y 7 r Application Accepted by C, Date VLA Are Pit or Grout Inspection by Date Final inspection by Date Additional Comments. Y 466-6781 --- ...i7 Lodi-369.3621-- 0-Manteca 823- 104—171-Trac835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Bax 2009, Stk., CA 95291 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO r� CASH +.EH 13-24 IREV.i/n 51 �q EH 14-28> ""1