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Y APPLICATION FOR PERMIT IE SAN JOAQUIN LOCAL HEALTH DISTRICT 1'i J-tJcl'C 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l sit . u1 (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 ;City t Size PM i Owner's Name� _ {� Fu Address " T rt Phone Contractor 1N hl'T��:l CW StAddress �. �L License No.� Phone 9A 'S(.4` , TYPE OF WELL/PUMP: II I NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION 11PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK P3 I f SEWER LINES ' DISPOSAL FLD. PROP. LINE t ' 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 F1 Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications r ❑ Public ❑ Other ❑ Delta Depth-of Grout Seal Type of Grout El Irrigation "Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ( State Work Done Well Destruction ❑ Well Dia_meter _- Sealing�CVlaterial"(top"50') Depthy f Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence Commercial_' Other Number of living units: Number of bedrooms_ r y ' I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypelMfg Capacity No. Compartments r PKG."TREATMENT PLT. ❑ ' +}—" ' Method of Disposal ' Distance to nearest: Well Foundation Property Line �l--z.. t � . LEACHING LINE n No_ & Length of lines r r t Total length/size I FILTER BED ❑ . Distance to nearest: Well Foundation ' ;Property Line SEEPAGE PITS ❑4 Depth " Size t Number SUMPS ❑. Distance to nearest: " Well "Foundation t 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 performanceof the.work for which this,permit is issued, I shall not em" "y any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifie 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 California." �� G Th plicant lst ca for all quir d ins ction . Co drawing on versa std . Signed X---.. itle: �.... —Da t ` rp FOR DEPARTMENT USE ONLY �7 7 Area i ✓ J � � I Application Accepted by Date Pit orlGraut Inspectio 1 � .Date �*Fria�lnspection by /r I 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH r RECEIVED BY DATE PERMI't'NO. $� + EH 13-241HEV.tia5Y - 21 rIr _ �_�` —EH 1426 VV CCC...JJJ�J 143,JS