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APPLICATION FOR PERMIT SAN JOAQUIN LOCALMEALTH DISTRICT 1'601—E: HAZEL T ON AVE4 STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,eby 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 Local Health District. rye, a /1 Job Address Z,0 City e PM Owner's Nam Address Phone i b Contractor dress V License No,i �� 73 Phone �� u TYPE OF WELL/PUMP:. , NEW WELL ❑ WELL REPLACEMENT —❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPA_ 1R LOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED_USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS $ ❑ Induial ❑ Open Bottom ❑ Manteca Dian. of Well Excavation Dia. of Well Casing I C�'ffamestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 71 Delta Depth of Grout Seal Type of Grout _ I I I IrrigationApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done W- -Type of Pump +`.. 1 H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50'1 y Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: # Number-oYbedrooms # f 71 Character of.soil- a'depth''of 3 feet: Water-table-depth. SEPT dfr TAfW Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ,1 Distance to neares . II Foundation Property Line LEACHING LINE ❑ No. & Length,of-lines a Total length/size s - FILTER BED ❑ Distance to nearest:' Well Foundation Property Line SEEPAGE PITS I I Depth Size f Number SUMPS w ❑ 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 ragula of the Joaquin Local Health District.+* Hama owner licensed agent's nature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any arson in such manne as to becom j t tg ' r man's compensation laws of California."Contractor's hiring or sub-contracting signature " cartifies t following: I certif t in the a e o e oris for which t ermit is issued, I shall employ ersons subject to workman's compensa- tion Y. P Y P ! P tion laws of California." / The app cant r requir i plate dra ing on re s side. Signed X ills: Z Z40 Date: 0001- ii it _ FORD ARTfNEN USE ONLY i Application Accepted by Date Area ip /7 Pit or Grout Inspection by Date Final Inspection by Date �/_n Additional Comments: 0 Stk 466-6781 ❑ Lodi 969-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 ' .Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 to INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PEERRMIT'NO. t/r EH 1324 1gE'V.i/H 57 Q EH 14-M-