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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA { t Telephone 1209) 466=6781 PeP,,—t' PERMIT EXPIRES TYEAR FROM DATE ISSUED 1_ (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 Local Health District. Job Address �� U 3 �� J r♦ —e e City ` Lot Size PM Owner's Name Address S 011 - P Phone Contractor L Address c�� a��.1 License No.-32 -_,(_'6Phone Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Y_ OTHER ❑ DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIVE # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS c, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial-- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing !_� Specifications M Public x Ll Other {1 Y 1-1 Delta Depth of Grout Seal f r Type ype of Grout I I Irrigation _-Approx.' Depth:lI 1 East ren Surface Seal Installed by I' Repair Work Done Type of Pump �'H:P- ! /0 State Work Done} G t Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth +Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is "� k available within 200 feet.) Installation will serve: Residence— Commercial= Other Number of living units: Number of bedrooms_ - Character of soil to a depth of 3 feet;.1 Water table depth SEPTIC TANK ❑ Type/Mfg! ' t Capacity �� m No. Compartments t PKG. TREATMENT PLT. ❑ " " Method of Disposal Distance td nearest: Well Foundation Property.Line .1 i a LEACHING LINE ❑ No. & Length-of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line 'I k SEEPAGE PITS I I Depth F } Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ tpst 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 Diltrict. 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." 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." f Y The ap m call for all req inspe ons. Co plate drawing on r e side, u . f7 14 A: Signed X Title: 4 " C Date: # FOR DEPARTMENT USE ONLY � � 1 Application Accepted by ))/,X Date / Area Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781—' ❑ Lodi 369-3621 ❑ Wrtaca 823-7104 '❑ Tracy835 d385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.0.,9ox 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE [,PERMIT NO. +.EH 13-24 1REV.1 51 �� Z� /}� (C a agl r EH 14-211 L� PL / j 1