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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j 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. '7 �J I Job Address S�-37. ��Llft/1�A1�� _ City Lot SizeCAU a�� PM ,91 Owner's Nam 0 1s J1.nr -_ Address 2a W, �`ull�+ 1�. Phone ` U 14- (� (] d Contractr� o��JK Address t�� L''rC a� `'tti rtit ° _. Lic nse No.c30LU2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L] I PUMP INSTALLATION E1 SYSTEM REPAIR Cl OTHER ❑ 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 U] Industrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia- of Well Casing 11 Domestic/Private [I Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public Cl Other r-1 Delta Depth of Grout Seal Type of Grout t I Irrigation ___.Approx. Depth I I Eastern Surface Seal Installed by _ a Repair Work Done L7 Type of Pump H.P. State Work Done Welt Destruction L] Well Diameter Sealirig.Material (top 501 1 Depth filler Material (Belo 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 (REPAIR)ADDITION l DESTRUC tON t I (No septic system permitted if public sewer is f available within 200.feet.I j Installation will serve: Residence— Commercial Other Number of living units: Number of b1drooms Z / { Character of soil to a depth of 3 feet "� -�— Water table depth 0 SEPTIC TANK ❑ Type/,Mfg Capacity I No. Compartments PKG:-TREATMENT PL T. ❑' "`r Method of Disposal F ^� Distance to nearest: Well Foundation T - � i .x,6n Property Line r j LEACHING LINE No. & Length of lines 7� �� dotal length/size A FILTER BED C1 Distance to nearest: WeO S0 FounAion_ -[ 1 Property-Line SEEPAGE PITS I IDepth > ' Size r Number SUMPS I I Distance to nearest: Well Foundation "" •,Propetty Line f DISPOSAL PONDS ❑ r _ 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. + i 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 j employ any person in such manner as to become subject,td;korkman's compensation laws of California." Contractor's hiring or sub-contracting signature i 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 us1 call for I required inspections. Complete drawing on reverse side.-"- tJ Signed X Title: v' �� Date: 7 FOR DEPARTMENT USE ONLY i Application Accepted by rDate ..-T Area Pit Or Grout Inspection by Date i Final Inspection by Date _,-_ Additional Comments: r' , ❑ Sik 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copiei to: Environmental Health PermitlServices 1601 E:fliazelton Ave., P.O.Box 4009, Sik., CA 95201 w IFEEO AMOUNT,DUE AMOUNT REMITTED-- CASH CK III— RECEIVED 9Y" DATE r7` /PERMIT'NO. + EH 17.24(REV. EH 14-26