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APPLICATION FOR PERMIT ;: S SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ry PERMIT EXPIRES TYEAR 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 1 Local Health District. Job Address �'- � Y _ _ _ - City Lot Size PM k _ Owner's Name Ll hP �n- Address Phone Contractor tuYnVe. LO'+ Address b`7 License No. Phone f _ _TYPE OF WELL/PUMP: , NEW WELL ❑ ;WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 i ❑ Industrial El _. Open Bottom ❑ Manteca ..--Dia:of Weli Excavation Dia. of Well Casing Ll Domestic/Private 4 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other } Fl Delta Depth of Grout Seal I � p Type of Grout `- I Irrigation f �%W —..Approx. Depth :l 1 Eastern Surface Seal Installed by' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter T Sealing Material Itop 50')' Depth Filler Material (Below 50') " ` TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION i I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence rte" Commercial_ Other j *+,� ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feta[: „"�-�-� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. t Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to nearest: Well' Foundation Property Line DISPOSAL PONDS ❑ 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. F Home owner or licensed agent's signature certifies the following: ".1 certify that in the performance of the work for which this permit is issued,.1 shall not employ any person 'n such manner as to become subject to workman's compensation laws bf California." Contractor's hiring or sub-contracting signature ` certifies the fol) "I rti_fy that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- If tion laws of Ca The applicant. all required inspections. Complete drawing on reverse side. Signed XTitle: `' �r<. Date: I _ FOR DEPARTMENT USE ONLY Application Accepted by � D e Area � . 1103 Pit or Grout Inspection by'kil 7 Date Final Inspection by Date Additional Comments: N t" A)Wffi §.Zlj� e_,�_' T ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE I T _ INFO AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE/ PERMiT'NO]� + EH 13-241fiEV.1i851 EH 14-28 - .