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�U APPLICATION:FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT i ; .. y,\ 1601 E. HAZEL T ONiAYE., STOCKTON, CA -telephone (20�j) 466-6781 PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED" (Complete in'Tripllcate)' "14 Lttn" 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 Ryles and Regulations of the San Joaquin Local Health District. r! _ it a� ,. .. s*-rg ., ti . �- '�.,,�•,• '`.'.. r ¢''3 n�js ' ., t Job Address `City `iw ►+, of Size QPM Owner's Name o N�� r - r F� Address'` g - o z. :, '�Phone Contractor, _.c4 } - F ^ 4 Address License No. Phone TYPE OF WELL/PUMP:, N W WELL'❑- y4/ECL'REPL'ACEIVIENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION Q SYSTEM REPAIR.❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER 0 SEWER LINES DISPOSAL FLD. lY — ' PROP. LINE i« FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS`—= INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . ML:•, Dia. of Well Casing ❑ Domestic/Private El Gravel Pack C1 Trac Type of Casing ❑ Public " Specifications ❑ Other ❑ Delta Depth of Grout Seal- ❑ Irrigation _A Type of Grout pprox. depth `Q Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, H.P, ' 1 State Work Done � ' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ff available_ within 200 feet.l,�.. -� I Installation will serve: ResidenceA Commercial Other �, <s Number of living units: Number of bedrooms s- r : i Character of soil to a depth of 3 feet: �S G Ii9J y`p�1?Z_ • SEPTIC TANK f� Type/Mfg 4 0 —Water table depth 0LP Capacity—_Aa o No. Compartments 2- PKG. TREATMENT PLT. ❑ it I 11� Method of Disposal r r Distance to nearest: Well !,?X, Foundation :X0 Property Line gS LEACHING LINE :No. & Length of lines �+' �O Total length/size zoo FILTER BED ❑,` Distance to•nearest: WeH { Foundation r7 Property Line ' 0 SEEPAGE PITS J "❑ ''Depth D� Size V. �= Number SUMPS r a i ❑ Distance to`riearest: Well _ Foundation [07 Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that.the work will be done in accortlance with-San'Joaquin courity ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. -.$ r $ Home owner or licensed agent's signature`certifies the following: 'I certify that i4.the perfgrmance of the work fo"Kwhich this permit is issued'I shall not employ any person in such manner as to become subject to workman's compgnsihon-laws of-Califormia:":Contracto s hiring or sub contracting signature certifies the following:"I certify that in the rformande of the work for wkich this ermit is issued;I shall ein fo F tion laws of California." p p y.persons subject to workman's compensa- tion The applicant must call for ail requi ed inspeec ' ns. C plete drawing'on reverse side. ; Signed Title: �.�-�rt7t-rat Date, :! 3 j `,FOR DEPA TMENT USE ONLY Application Accepted byE f Date Area I Pit or Grout Inspection by # ' Date Final inspection by ate Additional Comments ❑ Stk 466-6781 ted_ Lodi 369-3621,x' anteca 823-7104 ❑ Tracy 835 6365 t r Applicant- Return.all•copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 FEE, ... INFO ¢1MOUNT DUE .AMOUNT,REMITTEDCAM RECEIVED BY DATE PERMI 'NO. +. +EH 13-24(REV.1/s 5) EH 14-26f .. � - - � � .. 1 �..s 19-7 �