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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT * �w 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6* 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. f � P Job Address !y City Lot Size, 1_7 PM dwner's Name ! Address)L/1-7 , Phone 3/ "/t/Z -b Contractor cess /!� ` 7i� J License fVb_ Phon� 2 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 PiTSYSUMPS a INTENDED USE J TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` D Industrial €D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 —Type-of-Grout ❑ Irrigation Jq t g pprox. Depth ❑ Eastern Surface Seal Installed by ; Repair Work Done ❑ fType of Pump N.P. State Work Done I - Well Destruction ❑ :Well Diameter Sealing Material (top 501 t �� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms �^ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg RIF Capacity2_� UO No. Compartments PKG. TREATMENT PLT. ❑ : Method of Disposal Distance to nearest: Well�•v�+ Foundation /0 Property Line7. V O �. LEACHING LINE ❑ No. & Length of lines y^ Total length/size f V FILTER BED ❑ Distance to nearest: Well JA) y Foundation , ( Property Line 2 Q O SEEPAGE PITS ❑ Depth '--Size . .�fj I Number-\A21) SUMPS ❑ Distange to nearest:—Well fLAQ Foundation_I 0 11'roperiy1ine _74 DISPOSAL PONDS ❑ .� i� d �.r ^� I hereby certify that I have,prepared this,applieation.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 agents signature certifies t6e'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." _ 1 The applica must call for require inspections. Complete drawing on reverse side. Signed "Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by "" Date �' �.^ Are,\ L� Y .._ yy Pit r Grout Inspection by Date Z Final Inspection bvllk_ ,�� f- Date r T r A ditional Comments: ' r r Stk 466-6781 E] Lodi 369 1 ❑ Manteca 823-7104 C1 Tracy 835-63% I Ap plicantt- 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. CASH RECEIVED BY DATE PERMIT"NO. + EH 13,24{REV.1/8 6) nJ �1101V -7 EH 14-26 O