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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA d Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t - r h 4 City_ O-" tot Size U GcC!E eSPM Job Address t " 1 Owner's Name Fes] y � -� tt �fAddress � � 7 a -14 lf ek 4 deAl- _ Phone 3� 9 J _r Ir vt Addres_s l License Na. Phone - Contractor-� •� ' ^ TYPE-OF-V11ECL"/PUMP: -`- '" -"NEW-WELL -=-WEL-L REPL-ACEME-NT- --..--- +DESTRUCTION-Q DESTRUCTION--Q— PUMP PUMP INSTALLATION SYSTEM REPAIR ❑ BOTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES ' ` DISPOSAL FLD.��C y° PROP. LINE/� - FOUNDATION -AGRICUL--TURE_ WELL �._-� OTHER WELL 5Q PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S'�_ ri 13B Industrial Open ottom ❑ Manteca,. 1 Dia. of Well Excavation_ZA Dia. of Well Casing 4 r � <-�ecificat � �omestic/Private ❑ Gravel Pack ❑ Tracy�µ7ype of Casing ,� ;" Spions < - q�•-- �q I 1 Public F1 Other r ' l� Delta Depth of Grout seal yl. b Type f Grout r 4 I I Irrigation /�_&..Approx. Depth H. I Eastern S�rface Seal'Installed by: Repair Work Done ❑ Type of Pumps H.P. 01 _Ste'te_W.or-k Done Well Destruction LIWell Diameter. r—Sealirig`Mti tehal Itop 50') r'" Depth Filler Material l8elow"50') �- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I ].(No-septic-system-permitted-if public sewer is 1 j available within 200 feet.) s Installation will serve: Residence Commercial Other t . - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ? 1 } SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal x 1 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 1 SEEPAGE-PITS F] Depth y Size Number SUMPS LI 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 Di?;trict. k Horne 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 j 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 must call for all requi ed ins coons:Complete drawing on reverse side, t Signed Xn11J►. Title: -— Date: V >'�3� FQR.DEPARTMENT USE ONLY ; Applicet Accepted by ,� Date J� Area ' („ b "�s� Date Pit r Gra s't spaction by Date�_ Final Inspection by (( Additional:Comments: -'i 1 - ❑ Stk 466-6781 ❑ Lodi 369-4621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 wap ?�on r✓• Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 d FEE AMOUNT DUE AMOUNT REMITTED of CK CASH RECEIVED BY DATE fPERMIT'NO. INFO � 0 Nr.EH 13.24(REV.I?K 6) • EH t4-2B