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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 : 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 1 made in compliance with San Joaquin Cob+hty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /y�"� � Cilk Cit t Lot Size/ % PM ; Job Address W Owner's Name � � P, Address' �n , Phone 9 � 6 Contractor L& F\ '�� hp L� I-"" Address �s O tLicense No.43—OffA-C4 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES•, - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t f'1 Public ❑ Other ❑ Delta T Depth of Grout Seal' Type of Group _ / - I I Irrigation w —.Approx. Depth ( I Eastern Surface Seal Installed by !"V\ Repair Work Done ❑ Type of Pump: H.0. i State Work Doni J'_ Well Destruction ElWell Diameter Sealing Material (top 5011 Depth A` Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIRIADDITION DESTRUCTION l I (No septic system permitted if public sewer is 4 available within 200 feet./ �V f Installation will serve: Re idence ommercial ther 1 i r ��-°�' " Number of living units: Number of b droomss Character of soil to a depth of 3 feet: i T -= -- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments # �-' PKG. TREATMENT PLT- 17I Method of Disposal -.._..+ Distance to nearest: Well Foundatron. Property.Line LEACHING LINE U,-.Ue-& Length of lines al lenge/size FILTER BED ❑ Distance'to nearest: Well-'�"`"""'"'""""F6undatidf �`""PRUperty Line _ o SEEP7c"G-f-PITS a�I I I Depth +� j" Size Number I M SUMPS ��6isiance'to nearest: Well Foundation Property Line /] DISPOSAL PONDS ❑�D # n� I hereby certify that I have prepared this applicatio and that the work will be done in accordant with San Joaquin county ordinances, state laws, and ` " J rules and regulations of the San Joaquin Local health District. �` f " * ' 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., oy any person in such manner as to become subject to workman's compensation laws of California.".Contractor's hiring or sub-contracting signature c rtffie a following: "I certify that in the performance of the work for which this permit is issued, I shall mploy persons subject to workman's compensa- tion laws a alifornia." The applicant t i f all quire inspe tI ns. m to drawing on re terse side. Signe Date: /] FOR DEPARTMENT USE ONLY Application Accepted by - l_�_ -��-• Myo �� Date l _ Area H h r Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: W12 - ` ❑ Stk 466-6781 _❑ Lodi.,.369-3621 .-. ❑ Manteca..-823-7104 - _ O Tracy ..835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 4 E. Hazelton Ave.,-`P.0- Box 2009, Stk., CA 95201 I l 1 i FEE AMOUNT DUE "AMOUNT REMITTED) I CASH RECEIVED) BY DATE PERMIT'NO. INFO ae +.EH 13.21(REV.1/4 51 �� Qd -70 O EH N-28 ill