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APPLICATION FOR PERMIT t 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) 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 welii pump and the Ryles and Regulations of the San Joaquin Local health District. Job Address( yr� ,QLs`L�' �. City -1d - Z12�4 Lot Size _ PM Owner's Name '�'' '�� Address Phone r_n... -•��, ��•«•� .,.n, P_rzi)au tn..,. 5 app;.i AMOUNT DUE .....-.,,.._.,..._.-, AMOUNT REMITTED Contractor Address �f�i�1� DATE l''t:fiMlT`NO. _--_ _ License No.._ __ Phone TYPE OF WELLIPUMP: _ NEW WELL --i WELL REPLACEMENT W DESTRUCTION I PUMP INSTALLATION SYSTEM REPAIR 7 OTHER " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ �.._.� DISPOSAL FLD. _,_ PROP, LINE _ FOUNDATION -- AGRICULTURE WELL -- OTHER WELL PITSiSUMPS INTENDED USE — TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 indu$tfiai v3 Open Bottom Manteca Dia. of Wall Excavation__ Dia. of Well Casing —__- Ci Domestic/ Private El Gravel Pack Tracy Type of Casing_ Specifications 0 Public 0 Other C3 Delta Depth of Grout Seal _ _ - _ Type of Grout G Irrigation __. ---Approx. Depth 17 Eastern Surface Seal installed Repair Work Done Type of Pump H.P.State Work Dona Well Destruction _ Well Diameter __.._ Sealing Material ,top 50•) Depth _._._ Filler Material (Below 54') TYPE OF SEPTIC WORK: NEW INSTALLATION 1—; REPAIR/ADDITION �i DESTRUCTION a (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence --Commercial Other _ _ _ Number of living units: _... _ ._ Number of bedrooms _ Character of soil to a depth of 3 feet: _ _ Water table depth SEPTIC TANK i_I TypeiMfg — Capacity. No. Compartments PKG. TREATMENT PLT. C] Method of Disposal Distance to nearest: Well Foundation — �Property Line LEACHING LINE 0 No. 8 Length of lines �� _ _ Total length isize..__ FILTER BED _ 0 Distance to nearest: Wall ._ Foundation — i —_ Properry Lina _ SEEPAGE PITS 01 Depth _ ._ Size _ Number SUMPS _ 0 Distance to nearest: well _ Foundation _ _ Property Line DISPOSAL PONDS u ha>ah.. ,.,.,. ..1.,,. a ,ave cavon 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." Cantractor"a 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 app' t m t call for If re uire in tions. Complete drawing on reverse side. Signed _ _ Tide: FOR DEPARTMENT USE ONLY ff Application Accepted by Date _�f�� Area Pit or Grout Inspection by Date Final Inspection by l i n U,___..— s d itional Comments: Sirk 466-6181 El Lodi 36.,4-3&21 " Manteca 823-7104 Tracy 835-M iicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haaelton Ave., P.O. Box 2008, Stk., CA 06201 EH 13-24 tREV. I, x r ; EH 14-28 FEE INFO AMOUNT DUE .....-.,,.._.,..._.-, AMOUNT REMITTED RECEIVED 6Y DATE l''t:fiMlT`NO. I a�t� r =79 ko ti I