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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 I (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 A 30 Ci Lot Size PM Owner's Name72249GU4 Me e 0=LVI!fYt_ Addressz� Phone a? c Contractor Address License No.-LZY"-_;-Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS El Industrial LJ Open Bottom LJM ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications 17 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--. I I Irrigation rox. Depth I I Eastern Surface Seal Installed by € Repair Work Done ❑ pe of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material {top 50'i —� r •1 Depth Filler Material (Below 50') N j TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I i {No septic system permitted if public sewer is r � � available within 200 feet.) r; !r � Commercial� Other V Number of living units: Z- Number of bedrooms Installation will serve: Residence -- Character of soil to a depth of 3 feet: ' Water table depth /0 6 SEPTIC TANK l Type/Mfg Capacity __._ No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispose! Distance t nearest: Well 80 Foundation Property Line LEACHING LINE 9K No. & Length of lines T- g Total length/size fZ O A Z L FILTER BED ❑ Distance to'nearest-. Well Foundation w �� Property Line f SEEPAGE PITS 14"-Depth Z S �_Size �7 'I Number /I _ SUMPS Ll Distance to nearest: Well / 6m Foundation d Property Line t DISPOSAL PONDS ❑ 1 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 Di§trict. 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 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 must call for all required inspections. Complete drawing on reverse side. //,,,,�� __ p Signed Title: Date: 41 FOR D PARTMENT USE ONLY A lication Accepted by date Area Pit r Grout inspection byL Date .01-4 D.` Final Inspection by Date �� 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 r I' FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO. CASH +-EH13-24{NEV,r i H 51 �n EH 14-26 !! p