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Y 1 APPLICATION FOR PERMIT 14 SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA " Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED d (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. Cit Lot Size PM r Job Address _ s r Addres � ' Phone Owner's Name 55 r License No ` L 2_2 Ph,, rl�_ Contrac Address 4® TYPE OF WELLIPUMP: NEW WELL El WELL REPLAGEMEN I © DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -^� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � L INTENDED b5E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Delta Depth of Grout Seal Type of Grout — 1 j��.a C"1 Public ❑ Other ❑ Approxi Depth l l Eastern Surface Seal Installed by I I Irrigation — State Work Done— Repair Work Done❑ Type of Pump. H P Well Destruction( ❑ Well Diameter Sealing Material (top 501 T Depth Material (Below 50'! TYPE OF SEPTIC WORK: ,NEW INSTALLATION'/"I "RCPAIR DDITION - DESTRUCTION i I�(Ntic system permitted it public sewer ise within 200 feet.) . s 3 Installation will serve: Residence"�"C mmer_-,� Other Number of living:units: _Number of oms Water table depth Character of soil a a"depth of 3 feet: r No. Compartments SEPTIC TANK ~❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT-.-0 property Line r Distance to nearest: Well Foundation•` LEACHING LINE }_f ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f f Size Number SEEPAGE PITS I I Depth t eri Line_ — SUMPS Distance to nearest: Well — Foundation� Prof p Y DISPOSAL PONDS ❑. - A I hereby certify that I have prepared-this application and that the work will lie done_in accordance with Ban Joaquin county ordinances;sstate 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 wR1cKthis'permit is issued, I shall not employ any person in such manner as signature to become subject to workman's compensation laws of California. " Contracei%s!sub'ectdo workmanring or t1scompensa certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of Calif nia." The applicant mu c I for all res t . rred inions. Complete drawing on reverse)"d /b Title:,, Date: %/�/ I Signed �. FOR DEPARTMENT USE ONLY a> Area Data � Application Accepte r out'Inspecti n by Oat -Final inspection by ate 'S -42i f Ad riionai Camrrtbnts: ❑ Stk 466.67$1 ❑ Lodi 369-3621- ❑ Manteca 823-7104 ❑ Trecy„_835-M5 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,'P:O.-Box 2009;Stk:, CA 95201 " FEE CK RECEIVED BY DATE PERMIT'NO. F AMOUNT DUE AMOUNT REMITTEfl CASH Q �}�} � 4 INFO p 00, .2/y) r r.-EH 13-24(REV.51 N 5) mou EH 14-2a , t