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x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES T YEAR FROM DATE ISSUED 1 (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. q1 S- Job Address City Lot Size r I' Yr f PM Owner's Name 44 ---------- Address �d~M" Phone 01 Contractor '►wr�� r zdress ! /w t License No./ �"&�; Phone fY Y22, TYPE OF'WELL/PUMP: . NEW WELL ❑ - WELL REPLACEMENT ❑ 'DESTRUCTION`❑'"" - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑* i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL :PITS/SUMPS —a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t' i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications . . r 11 Public ❑ Other C] Delta 'bepth of Grout Seal Type of Grout _. I I Irrigation _-Approx. Depth I ] Eastern Surface Seal Installed by _ (� Repair Work Done ❑ Type of Pump H.P. State Work Done_ y Well Destruction ❑ Well Diameter Sealing Material (top 501) j Depth t Fillet Material;-f Below I - t It TYPE OF SEPTIC WORK: NEW INSTALIA ON I� REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial-_^ -Other= -_ -�--- - i Number of living units: Number of bedrooms ' .y Character of soil to a depth of 3 feet: 4 Water table depth SEPTIC TANK ❑ Type/Mfg` (_qnaCity__L No. Compartments PKG. TREATMENT PLT. ❑ t "F-.ndatio Method of DisposalDistance to nearest: a Property Line �. 1 LEACHING LINE ❑ No. & Length of lines ? Tot I length/size FILTER BED ❑ Distance to nearest: ell� oundation Property Line i SEEPAGE PETS I 1 Depth Size �` SUMPS ❑ Distance to nearest: Well&_0W�-Foundation_ U Property Line p DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and I 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 riot 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 applica t must callIf ll require 4`inspectidh'd Compl6te drawing on r6Qii a side. Signed r Title: � �� Date: FOR DEPARTMENT USE ONLY � t Application Accepted by b . ,/ G-tIt+..JC.�'�►• Date 'z`/ Area G � s Pit or Grout Inspection by Date Final Inspection by Date 1 �4 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' rt , n. IIt NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE w'f?ERIUIIT'NO. t + EH1 3-24 1REV.1 i H 51 x O`C/ _�5�6� I. EH 14-26 -- O O