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APPLICATION FOR PERMIT Q IN LOCAL HEALTH DISTRICT L1 .c�� :SAN JOA U t � 1601 E. HAZEL T ON 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 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 G – City jr�n/'Z Lot Size ©P k 9– M fl"" G� �` / y A�d �//�� Gly � I fe Phon %�G/r �/t e Owner's Name as Contractor IV'.* S Address r'7A/N S T IPClY _License No. Phone k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION 171, SYSTEM REPAIR ❑ OTHER ❑ / � f DISTANCE TO NEAREST: SEPTIC TANK Z SEWER LINES 0 DISPOSAL FLD. PROP. LINE Sd FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial XOp.n Bottom ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`i Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth t I Eastern Surface Seal Installed by _ '{ Repair Work Dane ❑ Type of Pump !r" 5•H.P. �/* State Work Done_ .n Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50') — y TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIRIADDITION i I DEST UCTION ( I (No septic system permitted if public sewer is f available within 200 feet.) ' Installation will serve: -Residence_ Commercial Other77 . = - Number of living units: Number of bedrooms ? Character of soil to a depth of.3 feet: Water table depth SEPTIC'TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ __ Method of Disposal f Distance to nearest: Well Fou tion Property Line 1 y LEACHING LINE ❑ No. & Length of lines= Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth ize Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 calf for all requir pections. omplete drawing on reverse side. 1 Signed X Title: Date: ' OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date��2� � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 d INFO r� OUNT^DUE MODUUNN�T RREMITTED ASIT CK (; RECEIVED 13Y DATE PERMIT NO. + EH 13-24(REV.1/851 EH 14-29 V rrrJ//tJVV V lJ