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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is haleby 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.1san 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. l r I Sdm�� 71 cr,I-of tLot Size PM Job Address 1 City Address �] _ y r I 30y,1 6f{1 Lp Phone Owner's Name Contractor J e 1 Address License No. Phone i! i TYPE OF WELL/PUMP: f NEVO�ELL ❑ WELL REPLACEMENT L1 DESTRUCTION ❑ PUMP INST�L[A'TION.❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI 'TfNi SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION�I, AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF'WELL PROBLEM A. EA - STA TI N ❑ Industrial El Open Bgtt�Om ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Fri Specifications ❑ Public ❑ Other } ❑ Delta Depth of Grout Seal Type of Groul '0 Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work�oD n'�e�G7 Type of Pump t H.# State Work Done I Well Destruction ,' Well Diameter Si ling Material (top 501 - �,,e Dept �' ilr Material [Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATI�' REPAIR ADDITION ❑ DESTRUCTION (No septic system permitted `f puff.c sewer is available within 200 feet.l 1, Ins serve: Residence Commercial- ther Number.of living units: Number of bed dooms --'^ �. Character of soil to a depth of 3 feet: er-table depth SEPTIC TANK Type/Mf -moi Capacity No. Compartments PKG.'TREATMENT PLT. 11 Method of Disposal I Distance,to nearest: Well Foundation Property Line LEACHING LINE ❑ No: & Length of lines Total length/size e1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth —Size Number SUMPS ❑ Distance,to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanceysyl state laws, and rules and regulations of the San Joaquin Local Health District. !l t 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub con pcting 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 workan's compensa- tion laws of California." I - The applicant st-call for II required inspections. Cornple drawing on reverse side. + Title: Date: kj Signed X FOR DEPARTMENT USE ONLY j Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspectio by Date Additional Comments: w � rO L] Stk 466-678.1 ED Lodi 369-3621 l ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1 1 E:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. INFO +EH 13-24 1 REV.1/H 51 /�. eA W11 x / 2-21-P I` EH 1428