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x y "/]i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r' PERMIT EXPIRES i 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 City Lot Size PM " Owner' 1 A s Nam Address � Phone �� — l o Contract Address •License No. Z Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' i FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications ' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Q 1 r- Repair Work pone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Pr REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units;--,L— Number of oms / Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK W--Type/Mfg Capacity yI No. Compartments I� PKG. TREATMENT PLT.❑ f l Method of Disppsal Distance to nearest: well 1— Property Line�— l LEACHING LINE 4- No. & Length of lines I — Total length/size FILTER BEd ❑ Distance to nearest: Well :0 -. Foundation 90 Property Line—4 F J SEEPAGE PITS Depth Size 33 _ Number „„ f SUMPS ❑ Distance to nearest: Well g� 0 r Foundation Property Line A 1 DISPOSAL PONDS ❑ d 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 I 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,I shall employ persons subject to workman's compensa- tion laws of California." T The applicant mu all for all r red . spections. Complete drawing on reverse side. Signed Title: P Date: J6 t,1 FOR DEPARTMENT USE ONLY Application Accepted by I I Date Area Pit or Grout inspection by Date-L .3,0 Final Inspection by AVA Date Ai Additional Comments; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ,. EH 13-24 IREV.t i s 51 EH 14-28 �d • U�