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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT u s L^� 1601 E. HAZE T ON AVE., STOCKTON, CA 3 3 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. I STt-KC.Ta� �.SX dao Job Address t � City Lot Size PM II` SEA- Ttt Wf4 Phone '(-0fs-66rz.."a$csQ' Owner's Name Eif�1,� G�• �� v Address C �AZ'o S , G A•• 4 Sa�,�+ Contractor 56t..R �!� Address AS A-SO" License No. Phone a TYPE OF WELL/PUMP:, NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4l' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TEYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ! -Approx. Depth l 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done fWell Destruction ❑ Well Diameter Sealing Material (top 501 De-�th Filler Material (Below 501 Jt ' TYPE OF SEPTIC WORK: NLW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION lNo septic system permitted if public sewer is iN available within 200 feet.) i Installation will serve: Residence— Commercial_ Other Number of living units: Li. Number of bedrooms I Character of soil to a deptF'!'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 Line LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ 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 parson 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." I The applicant must call for a("Irequired inspections. Complete drawing on reverse side. b Signed X� (19—RF a GI�L - -- Title: Date: ��0 0 FOR DEPARTMENT USE ONLY Application Accepted by Date T Area Pit or Grout Inspection by �!' Date Final Inspection by Date A L' Additional Comments: ,II z arM! - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies;w: Environmental Health Permit/Services 1601 E- Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [ FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BYDATE PERMIT'NO. INFO F + EH 3-24 EH 24IREV.1/N 10- =�f�-