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APPLICATION FOR PERMIT Z10 SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 3 2-1 2-1 , 11 Application is holeby 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 i Local Health District. t} �D0 3 Job Address City Lot Size T Ar PM i' -�Ir.I_T f P ww Address Phone re Owner's Name Ad Contractor -�II�tdress747J � License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ —8d O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX q 4.�;r t.IG76 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SP4e WisaUQW_ _ M Public n Other . ❑ Delta Depth of Grout Seal lvpa_el-.Gce�t I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - u- W Repair Work Done ❑ Type of Pump H.P. State Work Done IF- At,%) T Z { Well Destruction O Well Diameter Sealing Material (top 50') Depth t Filler Material (Below 50') �. TYPE OF SEPTIC WORK; NEW INSTALLATION I:i REPAIR/ADDITION [ I DESTRUCTION I I (No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. ❑ Method of Disposal ^ Distance to nearest: Well Foundation Property Line +`bn LEACHING LINE ❑ No. & Length of lines Total length/size �+ 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line r r [ SEEPAGE PITS I I Depth 1i I Size _ Number 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I 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. I Home owner orlicensedagent'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 follolV�ring: "I certify that i e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal' i ` The applica m s al �,,%�Con omplete drawing on reverse side:.`, Signed X f Title: 5 ph" Date: F R DEPARTMENT USE ONLY Application Accepted by Date 8/ `Area rf L11 pc*Fq,(ate i Pit or Grout Inspection by bate Final Inspection by Date f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520FEE ' I ,f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IR EV.i/m5) G0y� EH 14-28 ✓ °r7 CO Q l(J • r I