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5- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone 12091 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 desctions of the San Joaquin ribed. This application is made in compliance with San Joaquin County Ordinance It . 549 for sewage or No. 18&2 for well/pump and the Rules and Regula Local Health District. Lot Size J PM Cit ! y Job Address Phone Address Owner's Name /J - �� Sj �L �,, �//5�✓,,,/��'�/ License No._._----Phone Q Contractor Address NEW WELL ❑ WELL REPLACEMENT ❑ DE$TRUCTiQN Li TYPE OF WELL/PUMP: � SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC.TANK _..,�� PITSISUMPS FOUNDATION ��--AGRICULTURE WELL OTHER WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL pial of Well Casing EI Industrial; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications r T e of Casing ❑'Domestic/Private ❑ Gravel Palk ❑ Tracy Type Type of Grout [`I Public - 1.1 Other f:1 Delta Depth of Grout Seal j `` .Approxj Oepth I I Eastern Surface Seal Installed by - 1 1 Irrigation State Work Done_ � Repair Work Done ❑ Type of Pump H.P.Sealing Material (top 50') f Well Destruction Weil Diameter ; �_�' I Depth --- Filler-Material (Below 50'1 TYPE m per OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlAOOITION DESTRUCT(OrN 11Iavaailable7pllwit in 200 feetit'ed i( pu r is installation will serve: Residence v `ommerc6l_ .Other ( - Number of living units: Number of be s f Water table depth Character of soil to a depth of 3 feet: ter:., No, Compartments ❑ Type/Mfg w _ _--_T Capacity SEPTIC TANK � `T Method of Disposal� '-PKG. TREATMENT PLT. ❑ .Property�`;' Line - -°' � Distance to nearest: Well Foundation �T � ` F 1: *T 1 length/size LEACHING.LINE �. No. & Length,of lines � 4 lr FILTER BED y ❑ Distance to nll Foundation Property Line no We 4 F _ umber SEEPAGE PITS `l I Depth ' * f Size df Well 1G�— Foundation Property Line SUMPS iLCt Distance to nearest: i �� I DISPOSAL PONDS L7 '` /r- ' F 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.Cocal Health District. Home owner or licensed agent's signatu:re'ceri fie0he following: "I certify that in the performance of the work for which this permit is issued, I signature shall-not �..� employ any person in such manner as to became subject to workman=s compensation laws of California." ploy ceosonshiring sub subject to woorkman1sgompensa- certifies the following; ' certify•that in the performance of the work for which this permit is issued,-('shall employ p 1 r tion laws of California." - .' The applicant must call for all required inspections. Complete drawing on reverse side. ��J Q C+� Date: (� D y�,� Signed XTitle: ---------------- '��/ f r -.e > pq p p TMENT USE ONLY I Date Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by / Date.- 3; f ' Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 .❑ Manteca 823-7104 ❑ Tracy 835 6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haze Ave., P.O. Box 2009, Stk., CA 95201 F RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE.. . -AMOUNTREMITTED; Y INFO r.ER 13-24(REV.1