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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA t Telephone (209) 466-6781 ' PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) No 1,k—, ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. lication 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. &u�Job Address City Lot Size PM Owner's Name ,!C.42 Address Phone v �� Contractor Address�3x/o / / ,/ �T,,,,.,_�License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ PUMP INSTAL ION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO EM A CONSTRUCTION SPECIFICATIONS ❑ Industrial Q Open Bottom ❑ M a Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public {=l Other 1. Delta Depth of Grout Sea] Type of Grout I I Irrigation _..Appy Depth 1 i Eastern urface Seal Installed by Repair Work Done ❑ Type of PumpH.P. State Work Done Well Destruction .0 Well Diameter Sealing Mater] t{top 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I t. DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Cammercial_ Other Number of living units: _L_ Number of bedrooms a.—,- Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (�J 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 l I Depth Size Number t" SUMPS ❑ Distance to nearest: Well Foundation Property Line r 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 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." The applicant must call for all required ins tions. omplete drawing on reverse side. t C� Signed X Title: p�J�� Data: ��0� K3 FO EPARTMENT USE ONLY J Application Accepted by CNl Date �'��v Area 0 Pit or Grout Inspection byDate Final Inspection by Date O t Additional Comments: YtL--cr- ,A— ` J� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 W Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT-NO. +.EH 14-2a-21 IflEv.1/R 51 45-S, EH 14 CJ V 1� g S-8� 777 JJJJ p C]