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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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 apocation 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 Disuiicct. Job Address l��S �.� � i2e/ nl City`63C,910A) Lot Sim PM Owner's Name _ �.�l PK Address —0Phone — - i Contractor ss1�7 �(� I License Noc360 252 Phone TYPE OF WELL/PUMP: NEIN WELL WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION � SYSTEM REPAIR u OTHER ❑ NOA DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES Z.Ing,1•6_ DISPOSAL FLDN�1�- PROP. LINE FOUNDATION 30 _ AGRICULTURE WELL A1-_At OTHER WELLALIA� PIT'S/SUMPS 4.'Q L)C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ l E. Industrial . ❑ Open Bottom O Manteca Dia. of WeV Excavation Dia.of Well Casing `5 j 6-Domestic?Private ❑ Gravel Pack G Tracy Type of Casing�� Specifications ❑ Public ❑ Other E Delta Depth of Grout Seal Type of Grou,&XIM ❑ Irrigation _Approx. Depth �❑��,,.E, m- am Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done j Well Destru Kion O Well Diameter Sealing Material (top 50') "r Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C7 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) S Installatlon will serve: Residence_ Commercial_ Other K Number of living units: Number of bedrooms Character of soil to a depth 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 r tt LEACHING LINE G No. & Length of lines Total length/size { FILTER BED ❑ Distance to nearest: Well _. Foundation^ Property Line SEEPAGE PITS ❑ Depth Size Number` SUMPS ❑ Distance to nearest: Well Foundation Property Line 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,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 shat 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 Ca(ifor The applicant Z- call l' —'��' �� d--•.; I for•all required inspe 9. Complete dV4ving on reverse side. Signed - Title:�L� � f ( � Date: F DEPARTi41ENT USE ONLY )r Application Accepted by Date Area 641i. PitGrout I dol (`.�1 Q pection by �:� 1 -tate_ :"� �� Final Inspection by CL Date Date Additional Comments: t ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - FEE AMOUNT DUE AMOt1NT REMITTED RECEIVED BY DATE PERMlT"NO, INFO -CASH i EH 14.26(REV.x,991 �oS.C� Z,0,3o ND 11-I©- EH 1L28 —