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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT APR 1 I"�� 1601 E. HAZELTON AVE., STOCKTON, CAr — Telephone (209) 466-6781 ENVIRO.�IE!�TAL P1cAL.TH MENTA 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 c struct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinan a No.549 for sewage or No.,11 or w Lpump and the Rules and Regulations of the San Joaquin Locale Health District. Job Address D 1 r d K .City �.1 Lot-Size PM Owner's Name N� & ._` ed/Address J I9 61 `—LI ' Phone 7.d 2 ,,f. � _q35'39 I Contractor IE 14 " (K4 Address 416 J C'"1✓_1S St License No. ` f32_1 Phone � - r f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Sd� 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 El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i'[ ❑ Delta Depth of Grout Seal .- Type of Grout ❑ Irrigation --Approx. Depth . ❑ Eastern Surface Sea] Installed by Repair Work Done ❑ Type of Pump ' H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION 0 DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) F Installation will serve: Residence= Commercial Other Number of living units: Number of bedrooms k Character of soil to a depth of.3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line I. SEEPAGE PITS ❑ Depth Size Number I SUMPS _ ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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." r1' The applicant must call for all required inspections. Complete drawing on reverse side. � L`t 1116 07X"IF Title: n Date: Signed X _ C v. of-©eA , Oft EP tRT USE ONLYA61 `L tit 1� --� ' Date Area �� Application Accepted by I/ I -141F Final Ins s �-' Pit or Grout Inspect' y Dat Inspection by Date Additional Comments: ; rr, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ElTracy 835-6385 Applicant- Return all copies to: Environmental Health Perm. /services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 9 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO" y i INFO CASH A a EH'13-2401 EV.tit;5. r �V � / -/� EH 1 4-2e