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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL:HEALTH DISTRICT 1601 E. HAZELTON'AVE.,'STOCKTON, CA TelepF one {209) 466-6781 'PERMIT EXPIRES-1 YEAR FROM DATE ISSUED "� pp {Complete in Triplicate} ,+ Application is hereby made to the San Joaquin LocalHealthDistrict 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. S / !�L /VIeT/�U s City W ' Lot Size 0 k ZyZ-- PM Job Address I ]CSN J { - e �7g �� I R '1 � Phon - ` �-Owners Name Address # i Contractor Address License NoR 774SIS hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT`❑ DESTRUCTIO Z GIF1L5 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4 DISPOSAL FLD. PROP. t1NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic)Private EDGravel Pack Tracy Type of Casing Specifications , ') ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout I!' ❑ Irrigation ---Approx.'Depth ❑ Eastern Surface Seal Installed by Tf Repair Work Done Type of Pump' H.P. State Work Done R Well Destruction /QI�J Well Diameter Sealing Material (top 501. k L� Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI ( .,septic s st m emitted if public sewer is N Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms I Water table depth Character of soil to a depth of 3 feet � (+ ��ss Capacity No. Compartments r r SEPTIC TANK 114- Type/Mfg' PKG. TREATMENT PLT. ❑ p Method of Disposal Distance to nearest: Well Foundation - Property Line ,f y 'ITotal length/size LEACHING LINE ❑ No. & Length of fines FILTER BED ❑ Distance lto nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth Size Number SUMPS ElDistance 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 regulations of the San Joaquin Local Health District. that in the performance of the work far which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify 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." The ap 'cant must I f l r red inspections. Complete drawing on reverse side. 1oN" v �r Date: Signed ori J�? Title: ` FOR DEPARTMENT USE ONLY ^� I � Area l Application Accepted by Date R` I �• Date Final.Inection by Date Pit or Grout'lnspection by , sp 4k , s , Additional Comments: ❑ Stk 466-6781 ElLodi 369-3621 [1Manteca 823-7104 ❑ Tracy 835 6385 _ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE�. AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. INFO ��- ,. 1 � gG1eo—1 S Z. +EH 13-24 MEV.t%9 5I —7 G'�� p 01c �7/, EH 14-28 -