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APPLICATION FOR PERMIT FT e 44 , ,.,. • . { SAN JOAQUIN LOCAL HEALTH DISTRICT x 1601 E. HAZEL T ON AVE ��. ., STOCKTON, CA %4 Telephone 1209) 466-6781 S E i? 13 PERMIT EXPIRES 1L YEAR FROM DATE ISSUED ENVIR0NMENTAL HEALTH (Complete in Triplicate) PERIMFUSER` ICE, 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. I q Job Address � 70 �CQ.Ctr� ri City Lot Size PM r Owner's Name Address Phone i Conttactor�_ Address t!n f°et -�3a License No 13?6 i Phone S � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR a10�, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS; ❑ Industrial ❑ Open Bottom EI Manteca Dia. of Well Excavation,`!" �.r Dia. of Well Casing homesticlPrivate C1 Gravel Pack ❑ Tracy Type-of-Casing r ' �— _ Specifications Cl Public Cl Other Cl Delta Depth of Grout Seal -_ Type of Grout_ _ I I lrrigalion _ Approx. Depth l I Eastern Surface Seal installed by Repair Work Done [Type of Pumpl,,� H,P. State Work Done P-1 Well Destruction ❑ Well Diameter. Sealing Material (top 501 Depth " - Filler.,-Material (Below 50') i TYPE.OF SEPTIC WORK: NEW INSTALLATIO'N`I-..—.REPAIRIADDIZION'i-I.-DESTRUCTION f I (No septic system permitted if public sewer is '"-- ' �-. ' / --- available within 200 feet.) Installation will serve: Residence_ Commercial" Otfier # 1 :Number of living units: Number.of bedrooms 4 Character of soil to a depth of 3 feel:'¢ Water table depth SEPTIC TANK ❑ Type/Mfg + Capacity No. Compartments PKG. TREATMENT PLT. ❑ °` �` E 1 Method of Disposal Distance to nearest: Well Foundation Property Line ) LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tolnearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number N SUMPS Cl Distance toynearest: Well Foundation Property Line DISPOSAL PONDS I I hereby certify that I have prepared this application and that the work will be d"one-in-accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Local Health DiMrict. '- 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 c6mpen4ation laws of California." Contractors 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 applicanctions. Complete drawing on r erre side. Si ned X t muall all require inspe 9 Title: Date: 72I' OR DEPARTMENT USE ONLY d Application Accepted by Date Viol-AAroa Pit or Grout Inspection by Date Final Inspection by Date L0 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK AkFEE z INFO AMOUNT DUE f AMOUNT REMITTED. CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.I/K5) f}.( {y p EH 14-26 J 1 .94-7/9 . 1