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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Ordinange No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address TD City I —Lot Size Acj't---PM _ Ul oSer11 Owner's Name d i"7 Address v Mao k c Phone S _e2 y� Contractor�� r �� i 4 Address PC)&Y License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHj=R ❑ DISTANCE TO NEAREST: SEPTIC TANK a_-' SEWER LINES �� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLV�Q-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �( ❑ Industrial ❑ Open Bottom ,Manteca Dia. of Well Excavation j> Dia. of Well Casing ,Domestic/Private INGravel Pack ❑ Tracy Type e of CasingjU y� � Specifications � "z5.5 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal , Type of Grout 2L_Owx { ❑ Irrigation 13A–'Approx. Depth �] Eastern 'Suiface Seal lr stalled by Repair Work Done C] Type of Pump S V.a H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION i❑ (No septic system permitted if public sewer is available within 200 feet.) 'Installation will serve: Residence_ Commercial i Other 3 r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ., Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 CalOwnia." Conttactor'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 m t call or all require inspe tions. Complete drawing on re arse side. Signed X -�� " Title: a !I 0/F'_ Date: 7734-97 FOR DEPARTMENT USE ONLY Application Accepted by -7i Date Pit oInspection by � �Date /r v ° Final Inspection by Date Additional Comments:C – - -+-tJ�Y `t's�— O.r-f?E– CL,g.r „_,...._.....,... ElStk 466-6781 ElLodi 369-3621 ❑ Manteca 823-7104 �Ln 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 CASH RECEIVED BY //// DATES/� PERMIT NO. + EEH H 143-24-26 PREY. /957 �� * VY ��/