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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 application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Oe? So City ` Lot" Size PM Owner's Name // ` r �'Adress Phone morel Lv � rner ......... .................................. i L Number of living units-1- : .------ Number of bedrooms ..-� L..----Garbage Grinder /Y�.:... Lot Size .... xk-le r..................... TYPE-OF WELL/PUMP: NEW WELL U WLLL KLF'LAC;tMLN I LJ uto I MUL,I SUN u PUMVINSTALLATION ❑ SYSTEM RPPAIA'❑•- — - --OTHER-[3=� i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout _. I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Purrip H.P. State Work DoneWail Destruction ❑ Well Diameter Sealing Mate.ial Itop 50.1 Depth + Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 1 A Installation will serve: Residence____ Commercial A Other Number of living units: Number of bedrooms /'� Character of soil to a depth of 3 feet: S AVAP Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments + PKG. TREATMENT PLT. ❑ � } t�! Method of Dispel 04e —N Distance to nearest: -Well Foundation Property Line 1AV1 ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WeII Foundation f r`PrtSpa ty'Line .. i SEEPAGE PITS I ) Depth Size Number SUMPS Ll Distance to nearest: Well ^ ` Foundation Property Line_ DISPOSAL PONDS ❑ s " 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 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, l 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. Signed X Title: Date: Ff.RR DEPARTMENT USE ONLY _ Application Accepted by _, � � �� ,_...• ___ ,_._, _ Date a-~ •' Area Pit or Grout Inspection by r� Date Final Inspection by Date Zl-�r7 Additional Comments: y ❑ Stk 466-6781 . ,._171 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATER PERMIT' NO. +.EH M24(REV.I/H5) '7�r 0�c �O EH 14-28 / 666 tel%