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APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601�EHAZE TON AVE.; STOCKTON, CA ' s " 1984 Telephone (209) Q66-6781 J1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,wS�yEA�HQU1N LOCAL t (Complete:in Triplicate).h olsrRjCT 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 Reg dReegltions of the San Joaquin f Local Health District.,r: s e F 1,f67 P T -rM�~ City Lot Size �7 r Job Address /,, i - C� Address ��,ePhone Owner's Name 4 Contractor's Name � • ansa Na. /� 2 3 7 G Phone TYPE OF WELL/PUMP: NEW WELL © 1WELL REPLACEMENT ❑ / DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR I� OTHER ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWERI.LINES _ X—ITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREjA CONSTRUCTION SPECIFICATIONS � L3 Manteca Dia. of Well Excavation Ll Industrial of Well Casing Innd�dustrial ❑ O Bottom Open " Specifications Type❑ Gravel Pack ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal ITypi of G� rul ❑ Public III Other ' ,E I Irrigation � rox:gppDepth El Eastern 'Srdace Seal Installed by El Irrigation of Pump H.P. f� State Work Done Repair Work Done i." Well Destruction El Well Diameter Sealing Material Itop 50'1 Depth ', ,* Filler Material (Below 501 J sysl 6 -, -TYPE OF SEPTICWORX:'-NEW-IN STALLATION-13-REPAIR-/ADDITION O�DESTRUCTION=d"alvailablle�wit n8200 feet'tted�fjpubiic sewer is O Installation will serve: Residence ' Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ElType/Mfg Method of Disposal (1 PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation Total length/size LEACHING LINE ❑ No. & Length of lines property Line I: FILTER BED 11Distanc;to nearest: Well Foundation SEEPAGE PITS [IDepth I SizeNumber SUMPS ❑ Distance to nearest: Well Foundation Property Line .. DISPOSAL PONDS ❑ 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 regul the San Joaquin Local Health District. " Home o or licensed a is signature certifies the following: 'I certify that in the performance of the work for which this permit is issued, I shall not 1 employ a y person in such ma er as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies t e following: "I certify t at i the perform a of the rk,for"which this permit is issued,l shall employ persons subject to workman's compensa- tion la of California. The app! ant must I r wired in ti a ng arse side. Date: Signed e• FOR DEPARTMENT USE ONLY / i Date r Area Application Accepted by Pit or Grout Inspection by data Final Inspection b Date Additional Comments: ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 82377104 ❑ Tracy 835-6385 Applicant- Return all copies to: En trvnmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ! — FEE AMOUNT DUE ' AMOUNT REMITTED CAS RECEIVED BY DATE PERMIt"NO. INFO +£H 13241REv.101831 !_ pti �^ ' •� ' "s �1 EH 1428