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APPLICATION FOR PERM1� SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZE T ON AVE„ STOCKTON, CA v Telephone (209) 466-6781 I 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 Jtric . Jab Addres �U � r . City Lot Size �a+5„ Owner's Name rr11 � i.fe C Address Phony`- �4 7 —� ^--z"--� T- ContractorZ C Address r se No:� a Phon ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP ]NST ALLATI= R t-SYSTEM_R_EPAIR ❑ OTHERf❑ DISTANCE TO NEAREST:<SEPTIC TANK SEWER LINES DISPOSAL FLD. RPROP. LINE " FOUNDATION ,AGRICULTURE WELL:Y 'OTI-1ER WELL ;P,ITS/SUMPS \ty .,IMEN pED USE [ . TYPE OF WELL \, P,ROBLEM"AREA CONSTRUCTION SPECIFICATIONS ' D Industrial ' ❑'Open•Bottom ❑ Manteca Dia. of Well Excavation 51 D a. of Well Casir'1g ❑i Domestic/Private ❑ Gravel Pack = ❑ Tracy Type of Casing_ —LL � ificat`lons f I1 Public ❑ Other I_l Delta: Depth of Grout Tiepe of Grout— it Irrigation _.-Approx. Depth Eastern - f urface Seal Installed by I Repair Work Done ❑ Type of Purpp ✓ H;P: _ Sate rk pane i Well Destruction ❑ Well Diameter. — s Sealing erial (top 50'1 Depth ,Filler.Material i e'low 50'5 _ TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRYADDITION l l `DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: 'Residence Commercial_ Other Number of living units: Number of bedrooms . 'r Character of soil-to e"depfh - ^- Water table depth SEPTIC TANK- Cl Type/Mfg- Ca - pacify No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal, }j Distance to nearest: Well Foundation 'Property Line r LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED E) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 laws of California." Contractor's hiring-or sub-conttacting signature i certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call r all required inspections. Complete drawing on reverse std Signed X t Title: Date: DEPARTMENT USE ONLY t) c _ F Application Accepted byL Date ` L Area 1 Pit or Grout Inspection by Date Final.Inspection by I ate Additional Comments: ❑ 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.Q. Box 2009, Stk., CA 95201 f � FEE AMOUNT DUE CK AMOUNT REMITTEDINFO i CASH RECEIVED 8Y DATE PERMIT"NO. a.EH 13-24(REV.IIR5) EH 14-26 1716r �T�� / U '