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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 (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 N�2 for w�eelUpump and the Rules and Regulations of the San Joaquin Local Health District. r��,, y 'fin' Job Address —7 rte' J� City C Lot Size l�� ! PM Owner's Name Address Contractor iCf y Address 2 d-J� J X04-0 40'14' se No. 6 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 EIOpen Bottom 1:1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public [7 Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation --Approx. Depth ( I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is (\ available within 200 feet-) �1! Installation will serve: Residence Commercial— Other Number of living units: I Number of bedrooms .3 Character of soil to a depth of 3 feet: Water table depth �1 SEPTIC TANK I"Type/Mfg CC14 �SYL Capacity fD 00 No. Compartments 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 ( I Depth Size Number SUMPS Ll 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. 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 taws 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 r quired inspections. Complete drawing on reverse side. cs 7 Signed X - -- Title: r�/C�41 Date: FOR DEPARTMENT USE ONLY Application Accepted by _ W,, l Date L_ Area F Pit or Grout Inspection by Date Fh2pl In io Date rrprAdditional'Comments: 3- 462E ❑ Stk 466-6781,3 • d Lodi 369-3621 O Manteca 823-7104 ❑ Tr Applicant - Return alkopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y 5 k y FEEAMOUNT,DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO .�+ EH 13241REV.I/H5Y EH 14-28 160 tom.. k