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;,_ APPLICATION FOR PERMIT n , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ILE COPY (Complete in Triplicate) l ' 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. may/ Job Address � KCity Lot Size r�� d PM '-� ,� a�0 Owner's Name eC�)�1/��✓� Address r P Phone d Contractor ' G is Address License 1l0._ �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 FOUNDATION AGRICULTURE WELL _�, Q_.'. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI6NS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ,/ Dia. of Well Casing r X Domestic/Private Gravel Pack ❑ Tracy Type of Casing onzZ_ _ Specifications &d y' FI Public � Other ❑ Delta Depth of Grout Seal �h z Type of Grout C-&,eidly f Q I I I Irrigation AWApprox. Depth I I Eastern Surface Seal Installed by__ _S!df7-e J`! I Repair Work Done ❑ Type of Pump SU-4 H,P. Q State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is t available within 200 feet./ Installation will serve: Residence_ Commercial— Other E Number of living units: Number of bedrooms G Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments PKG. TREATMENT PLT.❑ Method of Disposal V Distance to nearest: Welt Foundation Property,Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PIIS l I Depth Size Number I SUMPS Ll Distance to nearest: Well Foundation Property Line O i DISPOSAL PONDS ❑ tom, 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, ander, f roles 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- lion laws of California." . The applicant must call for all required inspections. Complete drawing on reverse side, Signed X �+ �. Title: Date; O DEPA � ONLY f Application Accepted by i f Date :_ z Area I a Pit or Grout Inspection by Date final Inspection by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 13 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazplton Ave., P.O. Box 2009, Stk., CA 95201 FEE[INFO MOUNT DUE A OUN7 R>��rr7M,�ITTED CKS CASH RECEIVED BY DATE PERMIT'NO, 1 13-2 (REV.1/95 1 +/r^ 0 114-2e y/ `P[ �� L k 4 p c