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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 'f YEAR FROM DATE ISSUED . (Complete in Triplicate) Ae' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desVrrbed. Lica dl is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations gf the San Joaquin Local Health District. Job Address S City /=o CIL Lot Size PM Owner's Name,44(SS 1 Address d i Phone -,;Z-7Y/ Aiver- r1Qoed Cpntractor(0512erj2p_Cm ar•-7Address Ad License No. 1Y667b Phone-f-209)6-37S7 "7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X3 50;1 bvri 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other l Delta Depth of Grout Seal Type of Grout I I Irrigation _._Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done �.'l'ts.:.r0 Y1!'le►-C� "7 ,a r��,r.reT� C' Well Destruction ❑ Well Diameter Sealing Material (top 50'1'v-H �:f2 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is 1 available within 200 feet-1 r�J Installation will serve- Residence_ Commercial_ Other Number of living units: Number of bedrooms Vi Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r 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 I I Depth Size Number SUMPS Ll 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 California."Contractor's hiring or sub-contracting signature certifies the wing: "I certify that i he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion law of Gali rnia." The ap licanOC II re pe tions. C plate drawing on rsa si Signed Title: Date: a� FOR DEPARTMENT USE ONLY Application Accepted by 34 _ Date�� Area Pit or Grout Inspection by ,/Y// Date Final Inspection by - Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. INFO H + EH 13-24IREV.i/H51 1 ], EH 14-26