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APPLICATION FOR PERMIT �. . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CAQ 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 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.. Job Address c `p O C CLTM City&J�n Lot Size PM Owner's Name r 0 Address tsti/ +"c+ ► ► y r r tW r y Phone Contractor l Mbi n Address W6 c.> A VAIa+ cN License No.QQ-0 -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOf PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other 17 Delta Depth of Grout Seal Type of Grout I I irrigation _Approx. Depth I I Eastern SudacI I Repair Work Done ❑ Type of Pump a or, Done kmjqi Well Destruction ❑ Well Diameter RW.,alr,a) Depth e 9;ateriawo n TYPE OF SEPTIC WORK: NEW INSTALLATION I I I /A ITION I T ? o Lt septic system permitted it public sewer is ,rr �. being arnpli f U{ �}��+L3V�ilahle within 200 feet.) Installation will serve: Residence— Commercta� Oth�`� alth Di�jJon Number of living units: Number of bedroo Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments d PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance 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. 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 followin : "I certify that in the pe or ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o alif The appli ant t r i c plate dra w eve se side. Signed Title: c Date: _ Q, FOR DEPARTMENT USE ONLY / Application Accepted by Date lbhil'2—Area. dv l Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED /ICAS1 RECEIVED By 1 DATE PERMIT-NO. + EEH 13-24 H 14-2B(REV.I/n 51 �/(} rl s c v t/' L.