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a APPLICATION FOR PERMIT -- SAN JOAQUIN LOCAL HEALTH DISTRICT 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 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. rill Job Address °J �) 7�� l' 9 C/ City[-YAtti1.71" Lot Size PM �z � �y ° Owner's NameF t- Address I -7 ��1 Phone Contract ] Address PQ, 110-K-767 ;� License No.13 2b 2� Ph one b S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION EI SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEARES IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI0IV-�- AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBL A CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom EI Manteca Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin Specifications FI Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ 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 C` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 44-'REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial k/ Othe !L-Jut Number of living units: Number of �drooms / Character of soil to a depth of 3 feet: Water table depth I - SEPTIC TANK P'--Type/Mfg T-7t,1C, Capacity ; L� No. Compartments PKG. TREATMENT PLT. ❑ 0 f Method of Disposal Distance to nearest: Well 100 Foundation__-110 Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LlDistance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL 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 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 r�u �callfll5eq Ire nspectionsComplete drawing on reverse sidpSigned X ` \ �`"� ✓ Title: Date: I C Cfs / FOR DEPARTMENT USE ONLY Application Accepted by '�- Date y[ Area Pit or Grout Inspection by �� Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE CK 9 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13.24(REV.I/-5i ,C> EH 14.26 -70