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ry v APPLICATION FOR PERMIT C� 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 Ryles and Regulations of the San Joaquin Local LHealthDistrict. Job Addres4�' y h SO J Lot Size--94AqO re5 pMd CW Owner's Name��Q +�Q Address9.11 U/ �L (3 I" one / Contractor Address � � "� License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION)L1: SYSTEM REPAIR X OTHER ❑ .... DISTANCE TO NEAREST: SEPTIC TANK � � SEWER LINES d�SJ --- DISPOSAL FLD. PROP. LINE _. f FOUNDATION A0 ^ AGRICULTURE WELL OTHER WELL PITS/SUMPS `C)' t INTENDED USE _ TYPE OF WELL—., PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O MantecaDia. of Well Casing Dia. of Well Excavation _ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications U Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout VVII ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P_ State Work Done WgIE Destruction Cl Weil Diameter Sealing Material Itop 50'} Q. Sf3 $tt Depth Filler Material(Below 501 �+ TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence k Commercial____ Other NumYier of living units:--)— Number of bedrooms_C_ tr Character of soil to a depth of 3 feet; Water table depth SEPTIC TANK ❑ Type/Mfg Capacityy No. Compartments PKG. TREATMENT PLT. Q Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Il..r SEEPAGE PITS ❑ 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, 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 La 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 shalt employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. La Signed Title: 14 E Date: J' FOR DEP TMENT USE ONLY +� Application Accepted by Date Area Pit or.Grout Inspection by Date Final Inspection by �� 1r7 Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 0 Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all pies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O_ Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOtFNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 13-24(REV.4/851 ER 14-263�� ` u