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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES TYEAR FROM DATE ISSUED G (Complete in Triplicate) r 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. �g /1? � Jab Address f f, Y ��a _ City r ei%A Lot Size PM „Owner's Name,.— [ 5 f,e Address 1,4 Phone / �1 fPhone 1 S` �- a Contractor -t t Address License No.9 !j� TYPE-OF WELL/PUMP: NEW WELL ❑ .. WELL"REPLACEMENT ❑ _ DESTRUCTION ❑_ PUMP INSTALLATION ❑; SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK± t 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 I] Manteca Dia: of Well Excavation Dia: of Well Casing L7 Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other CI Delta Depth of Grout Seal Type of Grout I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by - _,__Repair_Work Done- ,.❑.,,...T.ype ofPump-..._: . r H.P. State Work Done 1 Well Destruction . ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material.IBelow 50'l ry r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION-I 1 DESTRUCTION i I _'(No septic system permitted if public sewer is • t i I '_ r available within 200 feet:I 1 r 1� � j4 •.�f f Installation will serve: Residence Commercial_ Other r i Number of"living units: Number of bedroo s i Character of soil to a depth of 3 feet: , a Water table depth' ^SEPTIC-•TANK------ Type/Mfg•�--]&- -P4 L eoill�:4 e apacify-71A(%jU'=N"o:Compartments PKG. TREATMENT PLT. ❑ �f t �'� Method of,Disposal l� Distance to nearest:. Well Foundation y� Property Line ; - � LEACHING LINE L/ -Total len� !�L No. & Length of lines � gth/size � FILTER BED ❑ Distance to nearest: Well Foundation -'�r Property Line'�i47 �. SEEPAGE PITS I I Depth r Size j '--Number SUMPS 'r L�- Distance,to nearest: Well Foundation �`Praperty Line i p , 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. �,{ '1 �y Home owner or lidensed agent's signature certifies the following: "I certify that in thelperformance 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 p('![mit isiss�ued,1 sh841 employ persons subject to workman's compensa- tion laws of California." The applicant must call for gli re uired inspections. Complete drawing on reverse side. . R f Signed X Date: � ..:A. L ( 1>' '`' -,,j FO EPARTMENT U5 ONLY'; r1, Application Accepted*by"- ----.1 Date Area `E j.. 17 Pit or Grout Inspection by Date Final lrispection by Dat r'`` Additional Comments: E 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 95201FEE INFO AMOUNT DUE' - AMOUNT REMITTED CK 4 ASH RECEIVED BY DATE PERMIT'No, + EH 13-24(REV.r i K 5) 7 e /f �}� EH 1426" - v v"