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w � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i. ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1.YEAR FROM DATE ISSUED (Complete in Tdplicate) _ 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,,: - - k . ICA D W () 1 % �14. x C .Y/ V I4Cot Size PM 60 s to Job Address Ly Owners Name C3 ILS J AR f,, Address `r` 'Sc) , `�� Phone Contractors Name -:Flovd�'&jMV3 License No. Phone TYPE OF WELL/PUMP: �, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ '.PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO -NEAREST: ,SEPTIC TANK SEWER LINES DISPOSAL FLD. x PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y # ❑ Industrial'*` ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ElOther 0 Delta ""P Depth of Grout Seal Type of Grout ❑ Irrigation —.—Approx. Depth El Eastern Surface Seal Installed by i Repair Work Done. ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ; Filler Material (Below 501 TYPE OF SEPTIC,`WORK: NEW INSTALLATION X REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is " 'avaifab{e•witKiin 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth. of 3 feet: k� L Water table depth SEPTIC TANK 0V Type/Mfg l— Capacity_ 7foi90___``- No. Compartments PKG. TREATMENT _ PLT. ❑- " Method of Disposal Distance to nearest: Well _ Foundation 30 / Property Line - I LEACHING LINE V'No'•& Length of lines "" Total length/size FILTER BED p ,❑' ,Distance to ngarest: Well Foundation Property Line 7ef� . k < SEEPAGE PITS Depth: —Size ' =Number 3` SUMPS ❑ + Distan a to.n__earest: Well Foundation /®Cl _ Property Line nicpncei pnivnc F1 I hereby certify that .1 -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: "l certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner.as4o-become-subject. to workman's compensation-laws.of-Califomia.-'� Contractor's hiring or sub -contracting signature certifies the following. "I certify that in the patformance 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 fo all raq ' ed inspactions. Complete drawing on reverse side. Signed ' Title: r Date: r FOR DEPARTMENT USE ONLY Application Accepted byDate Area D Pit or Grout Inspection byll_} �I Date Final Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi- 369-36214- ^^-° ❑ Manteca -82341104-0 Tracyc8354385 Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13 24'WV :18/831 EH 1428 INFO AMOUNT DUE AMOUNT'REMITTED CASH RECEIVED BY-- DATE PERMI7N0.