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r; APPLICATION FOR PERMIT YMf''w SAN JOAQUIN LOCAL HEALTH DISTRICT T 14 1601 E. HAZELTON AVE., STOCKTON, CA to b Telephone (209) 466-6781 A�a 2 0� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �Mp4S�t 5� 1•# (Complete in Triplicate) Nv�RQ 5EWOC� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des? 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. Jab Address A ? city�ot Size PM + Owner's Name �-^-� r 9 �A ddress�2 ` Phoneq/J ''A 3 7 e Contractor's Name � `�� b` License No. / 3"Z.�� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION lid SYSTEM REPAIR ❑ OTHER Q DISTANCE TO NEAREST: SEPTIC TANK " Q SEWER LINES A;S DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I-eppen Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing _ &-Cfomestic/Private ❑ Gravel Pack Ll Tracy Type of Casing S: c-,--I- (]Specifications El Public C-1Other ❑ Delta Depth of Grout Seal - a TCType of Grout ❑ Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump in N.P. 3 — State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 _ Depth Filler Material (Below 501 T E OF SEPTIC WORK: NEW INSTALLATION ❑ -REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -,.,�,,. r• t available within 200 feet.) f Installation w e: Residence— Commercial_ Other Number of living units: Number-of bedrooms Character of sail to a depth of 3 f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ��'• Method�ofD!BpoSal Distance to nearest: Well dation Property Line LEACHING LINE ❑ No. & Length of lines oh/size FILTER BED ❑ Distance to nearest: Well +, Foundation Prope ne r � SEEPAGE PITS © Depth . Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that l 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. I Home owner or licen-d1genYs 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 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 cared inspections. Complete drawing on reverse side. Signed XTitle: Sf Date: �+ �`�� -- _ OR QEPARTiMENT USE ONLY Application Accepted by Date Date . Area .�� . Pit or Grout Inspection by Dat Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 4W3621 ❑ Man eco 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 CASH RECEIVED BY DATE PERMIT"NO. INFO + EH 13-24(REV.101931 k. EH 14-29 .41 r _l