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ti J APPLICATION FOR PERMIT is SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA /' I Telephone (209) 46676781 I /_ -34 3 J 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 well/pump and the Rules and Regulations of the San Joaquin 1 Local Health District. - f ` Jab Address _ �1 �1t �r �'l Q��- Owner's Name , f City Lot Size PM f !� t � Address 3d � UP F—� u i r► _ Phone a IOU OU `\ C Contractor t 4 Address %I License No. Phone �� + TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE L v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack-, ❑ Tracy Type of Casing Specifications } M Public 1=1 Other f F1 Delta Depth of Grout Seal Type of Grout - I I Irrigation --.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump` H.P. State Work Done Well Destruction ❑ Well Diameter, Sealing Material (top 501 Depth r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION XINo septic system permitted it public sewer is available within 200 feet.) Installation will serve:" Residence;J Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of.3 feet:' Water table depth SEPTIC TANKi ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �. Method of Disposal -A r Distance to nearest: Well � Foundation, Property Line w� f-1 t LEACHING LINE LINE ❑ No. & Lerigih of lines. Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line } SEEPAGE PITS' I Depth I Size ' Number SUMPS 0 Distance to nearest: Well Foundation Property Line i r DISPOSAL PONDS ❑ 't'`' - - - - - 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 as to become subject to workman's compensation laws of California." Contractors hiring or sub-con6acting�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." s A The applicant must call for all7requad insseec onnss. Complete drawing on arse side.,Signed X l 1-��t'� Title: 0 �g � FOR DEPARTMENT USE ONLY ^� Application Accepted by Date 4 � Area i Pit or Grout Inspectio Date Final Inspection by _� �— Date " - ' C Additional Comments: Zi 44 h�i�� ISL L — ❑ Stk 466-6781 O Lodi 369-3621 ❑ Mae ca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. INFO a EH 13-24(REV,I/K5) EH 14-26 v