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i I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) iA 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 r Local Health District. f Job Address log O � & J�4 - �A R-c.k City Lot Size b30"-A A??--, PM �2` Owner's Name Address Phone 1. 35 Contractor's Name License Na. Phone .k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ p DISTANCE TO-NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS r k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f7 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . V ❑ Domestic/Private ❑ Gravel'Pack ❑ Tracy Type of Casing Specifications 9 ❑ Public ❑ Other { ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ElEastern Surface Seal Installed by ,/ Repair Work Dane ❑ Type of Pump H.P _ State Work Done4 + Well Destruction ❑ Well Diameter j Sealing Material atop 501 Depth E Filler Material (Below 50') ^^ R TYPE OF SEPTIC WORK: NEW INSTALLATION ISS' REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is I - I available within 200 feet./ Installation will serve: Residence� /Commercial-=Oth r . Number of living units: _� Number-of bedrooms.. 3 Character of soil to a depth of 3 feet.:.- 1 } f d Water table depth SEPTIC TANK C�3'i Type/Mfg Capacity leo,;nX No. Compartments Z PKG. TREATMENT'PLT.❑+; ( Method of Disposal Distance'to nearest: Well_✓66 f Foundation�' _ Property Line LEACHING LINE Q'iNo. & LengthTD of lines x-1�� _ Total length/size �x FILTER BED ❑ Distance to nearest:-*I Well Foundation Property Line �✓ SE6AGE PITS Ll Depth ' s Size Number SUMPS ❑ e Distance to nearest: Well Foundation _Property Line DISPOSAL PONDS ❑r �y 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 A to become subject to workman's compensation laws of California."Contractors 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:" The applicant must call for all r red inspections. Complete drawing on reverse side. r _ g Signed X Ywp.: Title: Date: y1 FOR DEPARTMENT USE ONLY Application Accepted by r� Date /� Area e-7 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE I AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH + EH13-24IREV.10/831 EH 14-28 OV 1 l-•,,,,, C?gsL� Q.11— �1 s 0