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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 1 YEAR FROM DATE ISSUED I� (Complete in Triplicate) a 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin j Local Health District. I� Job Address City Lot Size PM Owner's Name. !� Address U36 .4 Phone II 1 r r License No. ZaPhone -3t,'?-S10 Contract ddress I TYPE OF WELL/ LIMP; i` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications FI Public F1Other Cl Delta Depth of Grout Sea! Type of Grout w i I Irrigation !' .-Approx. Depth I 1 Eastern Surface Seal Installed by �- t Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below-50'.) — I TYPE OF SEPTIC WORK: NEW INSTALLATION -REPAIR/ADDITION LI DESTRUCTION I,IYINo-septic system permitted if public sewer is y "'f available within 200 feet.I V�] Installation will serve: Residence�::Cbmme�alb ;Other Number-of living units::- �']Number of drooms__.-. aa_ . ,... 1 CharacterAIVof soil to-a depth of-3 feet: Water table depth - ' ` SEPTIC TK�.. `� '? ,Type/Mfg Capacity�_(ZIQC — No. Compartments PKG. TREATMENT-PLT. ❑ I� ., L'I - .-1-_.t 1 � `',� Method of Disposil Distance to neares Well� Foundation A Property.Line LEACHING LINE No. & Length of lines Total length/size XCR FILTER BED ❑ Distance to nearest: Well_.. � Foundatioin,�a_ Property Eine �+�.,r r SEEPAGE PITS ><IlDepth Size �' t Number SUMPS Cl ilDistance to nearest: Well Foundation ^i(� Property Line DISPOSAL PONDS ❑ I hJreby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anto. 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,l shall employ persons subject to workman's compensa- tion,laws of California.' The applicant m call-for re- ired inspections. Complete drawing on reverse sjt i. tVY , Signed X Title: '^. r' x Date: Aj- qn :p - FOR DEPARTMENT USE ONLY G Application Accepted by 1 \ Date LV T ` Area 3 Sit�o Grout Inspection by Date inal Inspection by /Vl Date {U I Additional Comments: I� ❑ 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 95201 Ih I FEE AM6UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO +.EH t3-24,1Rev.i/851 •' �� • EH t4-28'� 0 II •