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APPLICATIONFOR PERMIT SAN JOAO,UIN'LOCAL HEALTH DISTRICT p 1601 E. HAZEL T ON DAVE., STOCKTON, CA TelepF ne (209) 466-6781 PERMIT EXPIRES'1 YEAR-FROM DATE ISSUED�v yi r"k (Complete in Triplicate) ". ". " -';!., ,'� ,' %. w - �: . Pit k v-; _7 .�- #i.. 'e a '`..;?.."5 4";; ''I bnB ii. ;-A ir,:�t , Application is hereby made to the San Joaquin LocaifHealth District fora 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. 4" Wt';; {fit, i - -i• } Job Address f �I �.:�-�L,v J I s s ,� Q �; - •R : 'a va l3' °r# City 'Lot Size PM Owner's Name Address 7` �1 u/ -C.tJ,JCn ,f/L�C�,t- Phone i i.� Contractor Address r, � 'Cicense NdL ,2Phone TYPE OF WELL/PUMP: NEW WELL ❑ " WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTAL'LATIO� ❑ _ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER E' WELLI- PITS/SUMPS INTENDED US -_V *PE OF WELL � PO_B RLEMA-RFA CO.NST-R.UCTJON_SP_ECIFICAT.iONS _ ___ _ ❑ Industrial J �❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 9 Domestic/Private ❑ Gravel Pack} ❑ Tracy Type of Casing— El asing �,.,;'Specifications ❑ Public. ❑ Other t # ❑ Delta Depth of Grout Seal 1 L Type;of Grout ❑ Irrigation —Approx.ID h ❑ Eastern Surface Seal Installed by t Repair Work Done t� Type-of-pump j .P. _ State Work Done -�, I �i . Well Destruction ❑ Well Diameter 3 Sealing Material (top 50') epthy € �� Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW iNSTAEL"ATION L) '-REPAIR/�` I D6 TION C1DESTRUCTION El (No septic system permitted if public sewer is; availbie within 200 feet.) \` ID Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth . SEPTIC TANK ❑ Type/Mfg. ~Capacity ]No. Compartments con PKG. TREATMENT PLT.TJ �' � �h1lethod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE- - ❑ -No. & Length of lines T Y I'length/:jize FILTER BED ❑ Distance to nearest: Well Foundation operty Line A � *, i SEEPAGE PITS ❑ 'Depth' "t Size Number" SUMPS ❑ Distance to nearest: Well Foundation Prop} - j party Line DISPOSAL PONDS ❑ i l `I hereby certify that I have prepared this application and that the work will be done in accordance with Sten Joaquin county ordinances, state laws, and 4 rules and regulations of the San Joaquin Local Health District. i 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."Contractors 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." The applicant st II fo aLLx ed inspections. Completedrawingn reverse side. } j Signed 7C= Date: 4 t" FOR DEPARTMENT USE ONLY " Application Accepted by r f � "Date Area J f Pit or Grout Inspection by Date Final Inspection by - " ate � (0 i Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 569-3621 ❑ Manteca 823-7104 ❑.Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permii/Services 1601 E. _Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 INFO AMOUNT DUE ., AMOUNT REMITTED _ CASH RECEIVED BY DATE PERMIT`NO. + EH 13.24IREV.1/85) EH 1426 .