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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED II (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 l 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. it i Job Address M�� Ci /01L 7l Lot Size PM 1 A � _ �� Owner's Name Address � Phone Contractor P�f 1541 54�P _AddressLicense No. Phone_ TYPE OF WELL/PUMP: NEW WELL Elf WELL REPLACEMENT E-1 DESTRUCTION Ell + i PUMP INSTALLATION 'Elfi SYSTEM REPAIR ❑ OTHER ❑ 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 } ❑ Industrialil ElOpen Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing Specifications ❑ Domestic/Private 1-1GravelPack ❑ Tracy Type of Casing P 1"1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation 1a 7 Aplir`ox oepth" t"t Eastern' Surface,Sea! Instaliild'by - { Repair Work Done ❑ Type of Pump r .H.P. a �* State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth �""'^�'^"""�"""'""�Ville► Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1REPAIR ADDITIO DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.! Installation will serve: Re idence Commercial_L30ther r Number of living units: - Number of bedroomp_ 4i Character of soil to a depth of 3 feet: �� r9 ; '� Water table depth �— SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,,I } Method of Disposal 1j rn Distance to nearest: Well Foundation Property Line h I LEACHING LINE No.`;& Length of lines �Tdtal length/size FILTER BED `' ❑ Distance to nearest: Well Foundation Property Line i I • ..i SEEPAGE PITS Size f �N_umbar � 1 SUMPS Ll Distance to nearest: Well Foundation '` Property Line DISPOSAL PONDS E] I I S I herebycertify that I have prepared this application and that the workWill be done in accordance with San Joaquin county ordinances, state laws, and - �., 2 rules and regulations of the San Joaquin Local Health D3trict. 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 Cali nia." i1 The applicant' call f all req "red 'ns cti mplete d awing on reverse ide. 7 GJ Signed X Title: ' Date: 1-I / T / FOR,DEPARTMENT USE ONLY a Application Accepted by �- Date 'rArea // �� L. ate Final Inspection by Date ////,,,rrrrrrplt i r Grout Inspection by - r% +r _ Additional Comments: 4-e6-C, l '� ; � �f�)5e - �t fir; L1 p o ter[ er 11 Stk Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 - 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ih FEE AMOUNT DUE; AMOUNT REMITTED CASH RECEIVED BY DATE PER 11T'N0. INFO 1, qa-->-® k +.EH 13-24 IREV.1/"5; , I EK a-26 ' f