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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCALFHEALTH DISTRICT \',r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'l YEAR FROM DATE ISSUED a °:C (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 Ryles and Regulations of the San Joaquin Local Health District. r, `Qa 17e/ f 0.. r '_ Job Address , •7 �. ':'r �`c City Lot Size PM Owner's Name Address _�� L� � , Phone 3 " 5 - Contractor i ddress �� t License No.u� 9,7 Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll ter • PUMP INSTALLATION ❑ _. SYSTEM REPAIR ❑ v � OTHER�D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES--' DISPQSAL-FLD. PROP_AE-=t_- 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 LlGravel Pack ❑ Tracy Type of Casing Specifications' 4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grouf ❑ Irrigation ---Approx. Depth ElEastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Wbrk Done_ 'l Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 0-(No-septic-system permitted if public sewer is 1 / available within 200-feet.)"- Installation will serve: Residence v Commercial Other ✓/� s� E Number of living units: Number of bedrooms aZ __- Character of soil to a depth of 3 feet: Water table depth D SEPTIC TANK Type/Mfg W eA,. ^� - Capacity ! 9Q p No. Compartments "i 1-1 ' Method of Disposal POPKG. TREATMENT PLT. Distance to nearest: Well Foundation_._ 44—t,Property Line /- kI LEACHING LINE A No.,& Length of lines S� Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation r = Property Line SEEPAGE PITS 13 Depth Depth Size .- , SUMPS ❑ Distance to nearest: Well Foundation I Property Line r DISPOSAL PONDS ❑ 4s 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." 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." ` . i +Il{E The applicant m st call for all required inspections. Complete drawing on reverse side. ; �•[J (J {// 1 F ' - - 11 - ,1 Title: Date- Signed � . FOR DEPARTMENT USE ONLY � 1 . I I P 7&� Area Application Accepted by � Date l �-��G Pit or Grout In by Date Final Inspection by Date S Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca .-823-7104,_ ❑.Tracy 835 q85 ��c e y�j G� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201 FEE AMOUNT DUE:; CASH I- AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO 1 + EH i3-24(REV,1/851 �� G7 �o�" �C7" gs 441;' EH W26