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r I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I� (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is i 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 City �! u ! I ri-Z 0 _ 9 Lot Size PM S � I q y Owner's Name o w4h I Address � r F, Phone $� �3a Contractor License No. `r one � Address Phone TYPE OF WELL/PUMP: �� NEW WELL WELL REPLACEMENT-17 DESTRUCTION,❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER. Cl— 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 0Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of'Wekl Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4 71 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout_. — I I Irrigation l� -Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done C Typie of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 r Depth Filler Material iBelow 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I l DESTRUCTION I 1 (No septic system permitted if public sewer is VN I available within 200 feet_i I Installation will serve: Residence Commercial— Other DO Number of living units: —,' - Number of bedrooms _ i Character of soil to a depth of 3 feet: SR6)12 Water table depth 0 SEPTIC TANK hType/Mfg Capacity &UrO No. Compartments a PKG. TREATMENT PLT. ❑ *1^' a! Method of Disposal -4F�CH 'distance to nearest: Well 1/0 Foundation Property Line 1Z_ F TEACHING LINE 0 `No. & Length of lines 3 - Q7 EpCN Total length/size Q FILTER BED Ll `Distance to nearest: Well �A7/ Foundation �S -- Property Line /60/ �7 F SEEPAGE PITS I I IlDepth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. 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." I The appl' ant st call for all r} red inspections. Complete drawing on reverse side. Signed X l \ Title: Date: �a 7-60 R DEP TMENT USE ONLY " ls� LZ2�1_=ZDate / Area s Application Accepted by Pit or Grout Inspection by I� Date Final Inspection b Date�� Additional Comments: li. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I� FEE AMOUNT DUE AMOUNT REMITTED H ZEIVED BY DATE PERMIT'NO. INFO 7 ^7 l' p + EH 13-24IRM 1/85) I EH 14-26 l�