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- APP_LICATION FOR PERMIT i -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKT'ON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SCANIkTED (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. Thisapplicationis 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. COPY Job Address 733 r City * Lot Size PM Owner's Name _Nt`c� a3 Address O 1/� S/ Phone Contractor Address _QS Git�Tise N` o� �v�/S Phone7_: i -_, TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT,*K7 PUMP INSTALLATI N Q „;SYSTEM'REPAIii ❑ OTHER ❑ 7.� � DISTANCE TO NEAREST: SEPTIC TANK. �' SEWER LINES DISPOSAL.FLD. PROP. LINE; FOUNDATION AGRICULTURE WELL _30— OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r�rY ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing�� Specifications f� Public T 6 Cl Other R Delta Depth of Grout Seal '�/E/. T ype of Grout ngafion __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ E Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Maferiai.46elow 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I ' DESTRUCTION I 1 INo septic system permitted if/public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet-- SEPTIC eet: Water table depth SEPTIC`TANK ❑ Type/Mfg C city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE CI No: & Length of lines Total length/size FILTER BED ❑ Distanc�to nearest:' W Foundatian Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation' Property Line DISPOSAL PONDS' ❑ hereby certify that I have prepared,this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 sh bt 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." The applicant mu fo d ins pe r s. Complete drawing on reverse side. Signed X Title: date- FOR DEPARTMENT USE ONLY 'Application Accepted by Date / Area Pit or to t Inspection by Date Final Inspection by Date �� Additional Comments: r r r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 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 FEE AMOUNT DUE' AMOUNT REMITTED CK RECEIVE BY ' "'DATE""" PERfd11T'NO. �i�Z� INFO CASH + EH 13-244REV.1ra 51 _ " IJ EH 14-26 l 0• VV L_444k__ Tom.Yl —ri 7 '7 e1� .�—�