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APPLICATION FOR PERMIT WAN JOAQUIN LOCAL HEALTH DISTR*'f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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!'he work herein s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Re I of a San Joaquin Local Health District. G Job Address 30 J- City 4 J1. Lot Size PM h�/t� PM Owner's Na oljrmress Phone 31 J er} i Contractor L+L/1✓UJ�?aL4 Address I �p 6/• � � ". U License N015ril Phoneya-24 07 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 N\ FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. I State Work Done _ r Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION NDESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet., Installation will serve: Residence Z Commercial_ Other Number of living units: —L- Number of becir oms z Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfgr CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal r Distance to nearest: Well Foundation Property Line r f' LEACHING LINE l� No. & Length of lines D '� T,otal length/size FILTER BED El Distance to nearest: Well t Foundation 1{,,t_ -z� ne�[��Property Li —s= SEEPAGE PITS fQ Depth Z.5 Size �' 3z /Number r SUMPS ❑ Distance to nearest: Well II;(L4 Foundation Property Line DISPOSAL PONDS ❑ 1 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. 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." The applicant must call for all required inspections. Complete drawing on reverse de. {�f60 Li Signed x / 1�i B � Title: _ Date: FOR DEPARTMENT USE ONLY �1 Application Accepted by ) ONLY Date HArea Pit or Grout Inspection by c Date ( Final Inspection by Date ,/ Additional Comments: I'1 t^ � a /�/"- ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 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 RECEIVED BY DATE PERMIT'NO. INFO CASH EH13-2.Ia EV.i i x 51J 0 1VV 0', yrU p /3 EH I4-2e �/ V