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APPLICATION FOR b _ . R PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone '(209) 466-6781 �� PERMIT EXPIRES 7 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.`.'' Job Address City Lot Size� M 'Owner's Name ' ss '•".� _ Tih�9Fe 's Phone V Y; ,n Contractor Address � i:l �+f /� � y License,No.e—�' Phone TYPE OF WELL/PUMP: NEW WELL �' WELL REPLACEMENT ❑ DESTRUCTION Q %t' } �. PUMP INSTALLATION iO SYSTEM REPAIR,,r3 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ",0 ( 4 'if' S SEWER LINES 1 ,$ DISPOSAL FLD. PROPXLINE FOUNDATION �,— AGRICULTURE WELL — AJ _ _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 9p�0n Bottom C Manteca Dia. of-We[?Excavatio _ V l Dia. of Well Casing # 1: Puomestic/Private O Grave! Pack ❑ Tracy Type of win_g/' t 9 Specifications + 1: Public ❑ Other C Delta Depth, GroufSeall_�""7JF T e Gr ut ! ❑ Irrigation Type :Approx. Depth u stern Surface Seal Installed by Repair Work Done C Type of Pump K'` k r H.P.� 1 State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') _ �\ ' _ I Depth Filler Material(Below 50').ti'R � - E. TYPE OF SEPTIC WORK: 'NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION"'G (No septic system.permitted if public sewer 0 l available Ovithin'�00 feet.) ' is is Installation will serve: , Residence Commercial—_ Other _ Number of riving units: Number of bedrooms E€ Character of soil to a depth of 3 feet.- Water table depth 1 Li SEPTIC TANK ❑ Type/Mfg r �}/ Capacity`_ No. Compartments PKG. TREATMENT PLT.❑ { Distance to nearest: Well o: {` Method of Disposal Foundation ,- r 0 Property Line r: LEACHING LINE ❑' No. & Length of lines Total length/size y i FILTER BED D Distance to nearest: WellFoundation y,_1i property Line IV; SEEPAGE PITS C Depth �'<) + j ' '- " } p Size Number l SUMPSJ' f ❑ Distance to nearest: Property iori Pro rlrSdaJtpy Line DISPOSAL PONDS Well FO Q. - ,✓r �'` i 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 C F rules and regulations of the San Joaquin Local Health District. r Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not r 1 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1 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 mu t call for all required inspections Complete drawing on reverse side. Signed .-�iB.��e r / 7 Title:, Date: FOR DEPARTMENT USE ONLY Q Application Accepted by L 61"- g- Date_�— Area Pit or Grout Ins • r Inspection by Date Final Inspection by D� 2ll i � t-'t/l' fY•lr.,�t��c� (�/�w4 / f Add i all omments: r e G Stk 466-6781 C3 Lodi 369-3621. ❑^Manteca 823-7104 . L•Tracy Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED } } 1 CASH RECEIVED BY' DATE PERMIT'N0. i EH 13-24(REV.i Y a 5) 1715^ D� �' P EH 1428