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4 41 R ' APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1PERMIT EXPIRES 1 YEAR FROM T DATEISSUED k (Complete„in Triplicate), ; Application is hereby made to the San Joaquin Local Health District foraermit to construct and/or install p a 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.' r W Job Address ti-0 7 • ��° Citi1. LlJP 7r � _ y - Lot Size PM Owner's Name ' Address `�'�� 7 //�'�—fes' A14 X 5; Phone }j a Contractor i Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ;K 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 Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ElOther 1' Q Delta Depth of Grout Seal Type of Grout i- ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump"I H.P, State Work Done_ 1 Well Destruction ❑ Well Diameterr� Sealing Material (top 50'1 4 Depth Filler Material (Below 501 _ TYPE OF SEPTIC.WORK:-,-NEW-INST,ALLATION'I]—REPAIR/ADDITION-❑--DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) _ r Installation will serve: Residence— 1Commercial_ Other. v ir v Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -I Water table depth SEPTIC TANK ❑ Type/Mfg +' Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to`Laresl-: —� Well Foundation Property Line t I LEACHING LINE ❑ No. & Length of lines} � :Total a gth/size FILTER BED ❑ Distance to nearest: Well_ P. Foundation ) Property Line ' SEEPAGE PITS ❑ Depths -S i7e Number SUMPS ❑ Distance to nearest: Well j f.' Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application'afi'd'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. 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." 4 e The applicant must call for//all requir inspections Complete drawing on reverse side. p^ Signed CTitle: Date: R A2 FOR DEPARTMENT_USE ONLY" Application Accepted by (;/ � �" " ' F --�•. pate Area _.__,,,., Pit or Grout Inspection by Data- 2 --'Final Inspection by Date;� Yom' i Additional Comments: _- I Stk 4&6-6781 - El Lodi 3&9-3621 w. Q Manteca 623-7104 ❑ Tracy 635-6385 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 RECEIVED BY DATE PERMIT NO. INFO r EH 13-24{REV.1/5 5) - EH 14-26. S x'!f ��/�� •13 �.-r,