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-1o ,ral " APPLICATION FOR PERMIT - SAN JOAQUiN LOCAL HEALTH DISTRICT " f 1601 E. HAZEL TON AVE.', STOCKTON, CA .) Telephone QW) 466-6781 2 A 'r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIR -V'ENTAL HEALTH Application is hereby made to the San Joaquin Local Health District fora ��!!�!I�/��1�1�iC�,� 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/ um and the Rules and Regulations of the San J Local Health District.--. A p oaquin Job Address . �V ll� f City / Lot Size PM Owner's Name - - I Address Phone Contractor r-447 -: Address 16 TYPE OF WELL/PUMP: NEW WELL ❑ License Not Phone 4 9 _ W€LL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR A OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE - PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION rSPECIFICATI❑ ndustial ❑ Open,Bottam ONS fI �x Manteca Dia. of-Well Excavation ( f' Domestic/Private ❑ Gravel Pack Dia. of Well Casing 1� ❑ Tracy Type of-Casing t C7 Public � ❑ Delta Specifications ❑ Other Depth of Grout Seat ❑ Irrigation ---Approx.-De t- h E Eastern Type of Grout Surfgce,Seal Installed by � Repair Work Done [�•- Type of Pump H P �� Y- i State Work Done Well Destruction ❑ Well Diameter Seating Material {top 50'1 Depth Filler Material (Below 501) TYPE-.OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No se'tic �N" �f� p system permitted if public sewer is Installation will serve: Residence—1 Commercial available within 200 feet.l Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: t,1`' �! F f Water table+depth yr SEPTIC TANK ❑ Type/Mfg r I Capacity j No. Compartments 771 TREATMENT PLT. ❑ �% !Method of Disposal Distance to nearest: Well Fou dation Property Line LEACHING'LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to earest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size 1 f SUMPSNumber ❑ Distance to nearest: Well, '`+ Fou6dation Pro DISPOSAL PONDS ❑ �? r pertY Line I hereby certify that I have prepared this application and that the woPk will be;done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heaiiii District: Home owner or licensed agent's signature.certifies_the.followinnd_,-'I.-certify'that in the performance of the work for which this employ any person g such manner i to become subject to workman's compensation Ows of California."Contractor's hiring orsub-contra ct ngmit is issued, lsignatushall re certifies the following: "I certify that in the�rformance of the work for which this permit is issued,I shall employ persons subject to workman's compen re # tion laws of California." The appiica ust II for all re /red inspections. Complete drawing on reverse side. Signed . I -5•i,r yy � f { !`tiTitle: Date: +ad r FOR DEPARTMENT USE ONLY Application Accepted by Date Area. Pit or Grout'Inspection by D ate --� Final inspection b Additional Comments: -� \1r y Date ❑ Stk 466-6781 D Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6.385 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 § INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.x/651 EH 1428 - ��