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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT na 1601 E. HAZEL T ON AVE., -STOCKTON, CA Telephone (209) 466-6781 ISD PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) r 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 I 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. JobAddress S' • " ��r City r Lot Size. x PM 64Q (07- Owner's Name Y I , 1 Address `-i�� _ Phone Contractor -Address #t��, �/l/4i3I� - License No. Z hone w, TYPE',OF_WELL/P LJ MP: EW.,WELL,❑_ �. WELL REPLACEMENT ❑ .w DESTRUCTION ❑ ' PUMP INSTALLATION'El ---SYSTEM REPAIR-171- "^'""""""--YOTHER--❑- f DISTANCE TO NEAREST: SEP "' SEWER LINES DISPOSAL'FLD. PROP. LINE FOUNDATION - RICULTURE WELL"`�-" 'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C ION SPE ❑ Industrial ❑ Open Bottom © Manteca Dia. xcavati Dia. of Well Casing I ❑ Domestic/Privat ---❑-Gravel Pack-�- R,Tracy--- —ype-of-easing---- -Specifications Private M Public F1 Other eta Depth of Grout Seal Typ rout - A I Irrigation _-Ap epth I I Eastern Surface Seal Installed by # ^�. i - Repair Work Done pe of Pump- H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material {top 501 ` y , Depth Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION l 1, DESTRUCTION* INo septic system permitted if public.sewer is € available within 200 feet.) Installation will serve: Residence_ Commercial Other * s f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK s '>< Type/Mfg Capacity No.-Compartments 6 PKG. TREATMENT PLT. ❑ _ Methodfof Disposal w Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTERBEDG ❑ Distance to nearest, Well Foundation Property Line SEEPAGE PITS I 1 1 Depth Size x Number f SUMPS L7 Distance to nearest: Well Foundation Property Line r 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. f it I 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 e , 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 mustcallfor.allrtequired-ins tions:,-Complete-drawing on reverse-side. Signed X Title: r e Date: NJ -FOR DEPARTMENT.USE ONLY r� Application Accepted b Date Area Pit or Grout Ins c. n Data Final Inspection by Date !6 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-6385 g 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 Imo. �S J `` + EH 13.24(REV.i/H s7 � - EH 14-26 I ...