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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 j 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 �Jr� �� CYt'�r 17d City C'SC�+Cvy Lot Size !� �lcr�s PM i Owner's Name A;re S Address Q C Phone ui live si3-s%�f� Contractor�'�r�° ' SOCY -,Address-CO-0 z,_- ._ License No. y 9 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 f2,\ DESTRUCTION ❑ t ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD. PROP. LINE ;A FOUNDATION } AGR ICU LTURE.WELL_----•OTHER_WELL PITS/SUMPS INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casin ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9 ❑ Domestic/Private ❑ Gravel Pack J a ❑ Tracy Type of Casing Specifications ❑ Public (71 Other f'�„❑'Delta.,} Depth of Grout Seal Type of Grout _ \� I I irrigation _Approx. Depth ��I h Eastern Surface Seal Installed by State Work Done Repair Work Done L-1Typeof Pump ` H.P. Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth "' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION/1 REPAIR/ADDITION l I DESTRUCTION I i INo septic system permitted if public sewer is '�'• ? Installation will serve: Residence_:Gommercial._.....Other-�6-iL //,o C available within 200 feet.) Number of living units: l Number of bedrooms 3 Character of soil to a depth of 3 feet: Ale GC Water table depth T ` /p5 e �'9.,C- ' Capacity 1�Oa No. Compartments SEPTIC TANK in Type/Mfg P Y PKG, TREATMENT PLT. ❑ .� Z t�,_3 � - Method of DF-" I Distance to nearest: Well lFoundation 1 U Property Line TS LEACHING LINE jZ No. & Length of lines �,'� ` " $S Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! h SEEPAGE PITS i I Depth /r, Size y�X AP I _ — Number - SUMPS V Distance to nearest: Well foundation As Property Line DISPOSAL PONDS ❑ l r 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, 1 shall employ persons subject to workman's c6mpensa- tion laws of California." ; I The applicant must call for all required inspections. Complete drawing on rdverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY----- Application NLY 'T`– --Application Accepted by Date AK4 Area Pit or Grout inspection by ' Date • Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 LD Lodi 369-3621 ❑ Manteca a23-71Servic s ❑ Tracy 6356385 x —', t _.. 1 Applicant - Return all copies to: Environmental Health Permit/Services 1t�i01 E. Hazelton Ave., P-0. Box 2009, Stk., GA 85201 FEEDAMOUNT DUE AMOUNT REMITTECK RECEIVED BY DATE PERMIT No. : INFO ,( CASH / ] r EH 13-24(REV.1/n 5) EH 14-26 V