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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. 4 Job Address �� City D f Lot SizePM Owner's Name lU _M!!:&tX 6. Address 7 D f�t (/�. L. -T- ) f - Phone - t . f P- f Contractor ' L , 6tti Address !� - "T�- /i iY License No. �$ Phone P —TYPE-OF-WELL/'PIJMP:--NEW-WEL-L C '---=----WEL-L-REPL_AGEMENT C-1.. ." DE81RUCTION-0. PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK ! 6 D z SEWER LINES DISPOSAL FLD.-rZ PROP. LINE e 1 FOUNDATION AGRICULTURE WELL OTHER WELL ,PITS/SUMPSI� INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS !t k ❑ Industrial pen Bottom ❑ Manteca, Dia. of Well Excavation Dia. of Well Casing .Domestic/Private ❑ Graves Pack �LI-Tracy ." - x Type of Casing ��C C i Specifications F] Public r ❑ Other' ',.. I rF1 Delta Depth of Grout Seal Type of gy°ut�ri1.i+t I I Irrigation r �--.._�lpprox. D�epfh "],i"I Eastern "''Surface Seal Installed by a t 1 f 1 f►�. _ Repair Work Done L1 Type of Pump" ) ]—�f P` � State Work Done Well Destruction ❑ Well Diameter _ (Sealing Material (top 50') Depth-, t Filler Material (Below 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION I"l REPAIR/ADDITION 1 I DESTRUCTION I 1 (No septic system permitted if public sewer is f` available within 200 feet.) r ' Installation will serve: Residence,6- ornm ercial_ Other Number of living.units- f Number of bedrooms Character of soil to a depthtiof 3 feet: Wate'r-table depth SEPTIC TANK "'" "� 0-- Type/Mfg Capacity No Carilpartments ry PKG. TREATMENT PLT. ❑ Method of'Disposal 1' l Distance to nearest: Well Foundation Property Line } LEACHING LINE Cl No. & Length of lines Total length/size— FILTER BED ❑ "Distance,to nearest: Well Foundation Property Line SEEPAGE PITS 1'i Depth Size Number j SUMPS h-i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 person in such manner as to become subject to workman's compensation laws of California."Contractors 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 requirAd 'nspactions'Camplate drawing on reverse side. Signed X L[ I-1 L 4;. Q�J d�09^'�..�Title: ,fie✓ � :.—�-- -- Date. I FOR DEPARTMENT USE ONLY f 1� Applicati n Accepted by t f DateArea v i_ L`� Si Pit or rp Inspection by ate �� Final Inspection by� Date Additi I Comments: ; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK 41 FEE i 7 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N`O. +"EH 13.2+(REV.r/ 5) EH 11-26 / r