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APPLICATION FOR PERMIT .w SAN JOAQUIN LOCAL HEALTH DISTRICT l `� 1601 E. HAZELTON AVE., STOCKTON, CA y1 Telephone (209) 466-6781 1 . ... w q ... PERMIT EXPIRES.1 YEAR FROM DATE ISSUED ,a� - ' ^ .• 21�:(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 applidation is made in compliance with-San Joaquin County Ordinance No.549 for sewage or No. 1862-for well/pump and the Ruies and Regulations of the San Joaquin Local Health District. 1-121 Y'- . , .:r]: , '- -:Q Job Address _� � v �,` �y {:City Lot Size PM A -l _ - - - Owner's Name, 4 ( - Address _� '� 1 d�1 IIA el_ Phone Contractor's Name s r S S icense No. Phone . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL RPL OBLEMM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E-xcavMi6ra P_ _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ElTracy.;.,,,.,��,,,... Type of sing Specifications a ❑ Public ❑ Other ❑ Delta Depth Caof Grout=Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern:do Ji �J Surface Seal Installed by• t Repair Work Done ❑ Type of Pump 1 H.P. State Work Done Well Destruction ❑ Well Diameter w --- Sealing-Material Itop 50'1 Depth i Filler Material,i Below.50'1 i TYPE OF SEPTIC WORK: ,NEW INSTALLATION ❑ REPAIR/ADDITIONiF .•.DESTRUCTIO INo septic system permitted if public sewer is ilable within,200 feet.! Installation will serve: tResidenWr `!I Commercial_ Other_ Number of living units ,Numbar,of bedrooms Character of soil to a depth of 3166t: 4 Water table depth SEPTIC TANK Type/Mfg + Capacity No. Compartments s+d.a. _ PKG. TREATMENT P i❑ a� Method of Disposal Distance to nearest: Well Foundation 1- Property Line_£ LEACHING LINE ❑ No. & Length& lines t'� Total length/size FILTER BED EIDistance to near .-t2 Wel Foundation Property Line SEEPAGE PITS A❑ Depth `• Size I Number — SUMPS ❑ Distance to nearest: " Wellt Foundation Property Line DISPOSAL PONDS ❑ i - 4 I hereby certify that I have prepared this app,lication and�thaf 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 ceiti ies the f6[1 "ng: "I certify that in the performance of the work for which this permit is issued, ! shall not employ any person in such manner as to become subject-t�f wContractors hiring compensation laws of California."Contractohiring or sub-contracting signature certifies the following:" certify that in the performance o{the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.' ' = The applicant st II for all re O '_sp ctio s. Comp a drawing on reverse sloe. Signed Title: Date: gb.,.�-.�:+....-. «.s+, .,rr�- ,� ,. � ..,•.,.�.,.f .. z--yw.,�-.�..e.� �t.��-,gig.-+-�+'—�d,.,�.ner��y FOR DEPARTMENT USE ONLY Application Accepted by Dates _ Ara Pit or Grout Inspection by Date Final Inspect' n by Date Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CASH RCK# ECEIVED BY DATE. PERMIT"NO. { INFO + EW 13.24(REV.101831 - �� 7 EH 1428