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t, f. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 41601 E. HAZE�-i O.N ,:\.E:, STOCKTON, CA �f 7 , " } Telephone (209) 466-6781 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the W.rklhert'in'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 a`rYd'Regula6oM3:of the San Joaquin Local Health District. j1 �Job Address 13 i �4� � L a,e_l Cit - of Size PM Owner's Name Address -59 � Phone ' md � � l�Z Phone �6 Z Contractor Address License No. TYPE'OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 21'1� OTHER ❑ DISTANCE TO,NEAREST':-,�EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �4-t-F0UNDATION• ---- r 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 r' Specifications f"1 Public F1 Other # ❑ Delta Depth of Grout Seal? Type of Grout ._. r -1 installed b U I I Irn�alion Approx. Depth Eastern S e Sea , y _ I Repaid Work Done (A' Type of Pump _ a H.P. State Work Done W Well Destruction ❑ Well Diameter Sealing Material (top 50'l I Depth Filler Material (Below 50'1 " - 7YPEOF SEPTIC WORK: NEW INSTALLATION I T REPAIR/ADDITION I ] DESTRUCTION l I"[N,o septic,sy tem permitted^,if public..sewer is / evadable within 200 feet.*b + i Installation will serve: Residence_ Commercial_ Other - ► .f Number of living units: Number of bedrooms w—�^ K o- a • Cha€atter of soil to a depth of 3 feet: Water tabledepfhV� e SEPTIC TANK ❑ Type/Mfg Capacity No. C mopartments— PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE 01 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f `I I SEEPAGE PITS I i Depth Size Number SUMPS L7 Distance'to nearest: Well Foundation Property Line I 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 sed a is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any , son in such nner as to b me sub workman's compensation laws of California." Contractor's hiring or sub-contracting signature { certifies the "I ce that in th ce o the work for which p rmit is issued, I shall employ persons subject to workman's compensa- tion laws f Caiif ni I The ap} ican u r ail re CompI a drawing n re s a. Signed Title: ghljy ..r FOR DEPARTMENT USE ONLY II Application Accepted by f�' Date Area " E! Pit or' Inspection by Date _ Final Inspection"by Date C_i l I � x Additional Comments: ❑ Stk 466-6781• ❑ Lodi 369-3621 ❑ 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 CK RECEIVED BY ; INFO CASH\_ ,, G6 DATE PERMIT'NO. +.EH 13-241REV.riesf EH 14-26