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APPLICATION FOR PERMIT ° SAN JOAQUIN LOCAL HEALTH DISTRICT J' 15/ 1601 E. HAZETON AVE., STOCKTON, CA No n j9 Telephone (209) 466-6781 �tVLC PG-i2 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 73 `--jG Z (Complete in Triplicate) Application is heteby 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. U j-- y L 7 C I / City Size PM Job Address U Owner's Name Address 2 G 5'7 ' Phone �V L — J Contractor Address 12 License No.�Phone TYPE.OF.WELL/PUMP: _ ,,_ �rNE.- .WELL_❑ ____WELL REPLACEMENT 17DESTRUCTION ❑_ s PUMP INSTALLATION ❑ SYSTEM PAIRY❑ OTHER LJ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LI ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS -e. ❑ Industrial - ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LJ Gravel Pack ❑ Tracy ype of Casing Specifications ❑ Public ❑ Other L-I Delta epth of Grout Seal Type of Grout—.—.- 1 rout ._1 1 Irrigation _Approx. Depth,.,..1_I,Easter Mantel �� urface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. a State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 f Depth 1 Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR IADDITIO i I DESUCTION [ (No"septic system permitted it public sewer is T I le wi in 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms tiWlk� V Character of soil to a depth of 3 feet: ter table depth SEPTIC TANK ❑ Type/Mfg {' Capacity No. Compartments PKG.`TREATMENT PLT. ❑ i " :Method of Disposal Distance to 46,rest: Well foundation Property Line 1 ' LEACHING LINE ❑ No. & Length of lines -- Total length/size FILTER BED El Distance to nearest: Well Foundation —Property Line SEEPAGE PITS 11 Depth ' Size Number SUMPS L-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 i rules and regulations of the San Joaquin Local Health Driltrict. , Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not k empioy'any'persori in such manner as to become subject-to workm-an's�ompensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: 1 certify.that in the performance of the work for which this permit is issued, I shall employ persons subjec-t to workman's compensa- tion laws of California." The applican u?t call fo required i ctions. Complete drawing on reverse side, ` Signed X Title: (�r/�f�'V`Z r .., .-,_— Date: 9-2 L I ° SOR DEPARTMENT USE ONLY._ a �L. t. Application Accepted by r � Date��b ` J Area ►'l B Pit or Grout Inspection by y Date Final Inspection byDate ~ - Additionai-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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMIT-NO. +.EH -241REV.iiH5) - J '00 EH 14-20 t'