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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 I� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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 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. { 1C1 j.�� Job Address 7�v��n F' � �y� City Lot Size PM N.. /V\Q�J A.{ � '� 1� � Phone Owner's Name 1�� -1y.,�sux ��''� Address � Contractor�tAIN \.LL0M'�Rsa icense No.4 3 Y Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing �- ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications rn FI Public Fl Other ❑ Delta Depth of Grout Seal Type of Grout Lr 1 I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material(Below 601 O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I RUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) G Installation will serve: Residence `!Commercial_ therT' Number of living units: Number o/bedrooms`, 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 _) Distance to nearest: Well Foundation Property Lina 1 LEACHING LINE N—'lqo—6 Length of lines �) Total length/size FILTER BED [I Distance to nearest: Well o0 Foundation--l1� Property Line /D0' SEEPAGE PITS Wd Dspth 7)15 Size Number SUMPS D Distance to nearest: Well Foundation� Property Line - 100-1— DISPOSAL 0ODISPOSAL PONDS ❑ — 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 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 arson in suc armor as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the wing:"1 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 Cali ia:' T applicant oat c for all re irad to dr ' g on re a side. Signed t e: MX= Date: / '//'/Y ///J/ FOR DEPARTMENT USE ONLY I/ Application Accepted by L' N/� Date " ' Z �T Area Pit or Grout Inspecti Data Final Inspection by Date. Additional Comments: t Uy^-J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑Tracy638& 5 T ' Applicant- Return all copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CABH RECEIVED BY J DATE rPPERRMR7NO. .EH 1324 fRW.11s51 Io- ('O EH a-24 �dl —