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APPLICATION FOR PERMIT : SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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.' e4 Job Address /ZQzn City Lot Size PM Owner's Name �✓ z •Zzrn Address ! Phone -1 icense No. QM ZZ3 Phone Contractor Address TYPE OF WELL/PUMP: v NEW WELL ❑ WELL REPLACEMENT X DESTRUCTION $1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ G DISTANCE TO NEAREST: SEPTIC TANK SD�'� SEWER LINES DISPOSAL FLD. PROP. LINE # _ FOUNDATION AGRICULTURE WELL OTHER WELL_La2_–_L PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N I D Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing Domestic/Private W Grave! Pack' ❑ Tracy Type of Casing P Specifications ❑ Public ❑ Other ' ❑ Delta Depth of Grout Seal oOlType of Gro lic ox. q Irrigation _-4pprDepth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction X Well Diameter ��_ f Sealing Material Itop 50') �� Depth t t��7t`7 Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is- f I available within 200 feet.) Installation will serve: Residence Commercial— Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet : Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line r � � I LEACHING LINE ❑ No. & Length of lines Total length/size 0 i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS .❑ Depth`I _ Size Number t 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, l 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." Theapplic nt m st call for all r it spections. Com ete drawing o r si e Signed Title: Data: n OR PA ENT USE ONLY I /� Application Accepted b ,DateArea I Pit or Grout Inspection ate(//2_ 1- Final Inspection by o`'y`J Dat I Additional Comment . "o 1 ❑ Stk 466-6781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1901 E. Hazelton Ave., P.O. Box S C FEE AMOUNT OUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO + EH 13-241REV.1/s5) Q` 4--7qC � EH 1428 C