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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA F! Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compfete 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. AA� �+ b Address _ZZ G�'� ZAGi Lot Size � �/ MS /� J• ty PM F1Owner's Name 41 Address V-e, ��' 'M.1AA0 A) Phone Contractor Address____'e'� y 6`;�- Ti.v-v License No. Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ h� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS fill INTENDED 0t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑Tracy -Type of Casing Specifications m El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - ❑ Irrigation —Approx. Depth ❑ Easter ; Surface Seal Installed by Repair Work Doiie ❑ Type of Pump H.P. State Work Done I �F. Well Destruction ❑ Well Diameter Sealing,Material Itop 50') Depth Filler Materiail (Below 50') kk TYPE OF SEPTIC WORK: NEW INSTALLATION 1K, REPAIR/Af} 'ITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence—L Commercial_ Other k" C Number of living units:.-/ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK TypelMfgcli ! 1 pacity $� No. Compartments PKG, TREATMENT PLT. ❑ fe7^-- Method of Disposal Distance to nearest: Wellr Foundation 6 Property Line IF32 _^ fit LEACHING LINE No. & length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line � I SEEPAGE PITS §e Depth A15L izeNumber " SUMPS ❑ Distance to nearest: Well Foulndation1 ��perty Line �� DISPOSAL PONDS ❑ . 4 1 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; "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subjectlo workman'spompensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this porn-tit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." - The applicant must call for all required inspections. Complete drawing on reverse side. f Signed XTitle:� .-t. Date: "�'�- _ FOR DEPAR MENT USE ONLY,, ` P Application Accepted by .Qate. Area �i Pit Grout In y by 9- F 'y Inspection b atey o�J— Final Inspection ... Date Additional Comments:T ❑ Stk 466-6781 ❑ Lodi M-3121 : ❑ 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 j E FEE AMOUNT DUE. AMOUNT REMITTED-' RECEIVED BY DATE? PERMIT NO. INFO CASH +EH 13-24(REV.I/B W Q• 3 EH 14-28